Provider Demographics
NPI:1992130017
Name:FLY BEHAVIORAL SERVICES, LICENSED BEHAVIOR ANALYST, PLLC
Entity type:Organization
Organization Name:FLY BEHAVIORAL SERVICES, LICENSED BEHAVIOR ANALYST, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, LBA-NY
Authorized Official - Phone:646-524-5984
Mailing Address - Street 1:111 W 117TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-1589
Mailing Address - Country:US
Mailing Address - Phone:646-524-5984
Mailing Address - Fax:
Practice Address - Street 1:159 W 118TH ST APT 1D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-1855
Practice Address - Country:US
Practice Address - Phone:646-524-5984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-09
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1063037OtherBCBA
1992130017OtherNPI
NY000135OtherLICENSED BEHAVIOR ANALYST
1497189104OtherNPI