Provider Demographics
NPI:1225574544
Name:MOUNTAINSIDE BEHAVIOR ANALYSIS SERVICES, LCC
Entity type:Organization
Organization Name:MOUNTAINSIDE BEHAVIOR ANALYSIS SERVICES, LCC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMONS
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:304-851-6643
Mailing Address - Street 1:25 THISTLE LN
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:WV
Mailing Address - Zip Code:26260-1104
Mailing Address - Country:US
Mailing Address - Phone:304-801-3258
Mailing Address - Fax:304-362-0025
Practice Address - Street 1:25 THISTLE LN
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:WV
Practice Address - Zip Code:26260-1104
Practice Address - Country:US
Practice Address - Phone:304-801-3258
Practice Address - Fax:304-362-0025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-10
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000550251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health