Provider Demographics
NPI:1568290062
Name:IC LICENSED BEHAVIOR ANALYSIS PC
Entity type:Organization
Organization Name:IC LICENSED BEHAVIOR ANALYSIS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ABA
Authorized Official - Prefix:
Authorized Official - First Name:INNESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-415-9046
Mailing Address - Street 1:3021 QUENTIN RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3021 QUENTIN RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4232
Practice Address - Country:US
Practice Address - Phone:718-415-9046
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty