Provider Demographics
NPI:1487155362
Name:MOMENTUM LICENSED BEHAVIOR ANALYSIS, PC
Entity type:Organization
Organization Name:MOMENTUM LICENSED BEHAVIOR ANALYSIS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, BCBA, LBA
Authorized Official - Phone:718-730-2814
Mailing Address - Street 1:3158 12TH ST FL 2
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-4804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3158 12TH ST FL 2
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-4804
Practice Address - Country:US
Practice Address - Phone:718-730-2814
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency