Provider Demographics
NPI:1902570443
Name:PROVIDENCE COMMUNITY ABA
Entity Type:Organization
Organization Name:PROVIDENCE COMMUNITY ABA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:L
Authorized Official - Last Name:NKEMATABONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-722-9152
Mailing Address - Street 1:5614 JOSHUA TREE CIR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-9341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 KASSY LN
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-6577
Practice Address - Country:US
Practice Address - Phone:253-722-9152
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-08
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty