Provider Demographics
NPI:1972185700
Name:FULL SPECTRUM ABA THERAPY
Entity type:Organization
Organization Name:FULL SPECTRUM ABA THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:317-318-4352
Mailing Address - Street 1:101 W MAIN ST OFC 217
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-1712
Mailing Address - Country:US
Mailing Address - Phone:317-318-4352
Mailing Address - Fax:765-217-7151
Practice Address - Street 1:407 MEADOW AVE
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-2718
Practice Address - Country:US
Practice Address - Phone:317-318-4352
Practice Address - Fax:765-217-7151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300048511Medicaid