Provider Demographics
NPI:1902573496
Name:EIGHTY-TWENTY LEARNING FOR ASD, LLC
Entity Type:Organization
Organization Name:EIGHTY-TWENTY LEARNING FOR ASD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/BCBA
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GLIDEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-926-9259
Mailing Address - Street 1:260 COUNTY ROAD 375
Mailing Address - Street 2:
Mailing Address - City:BONO
Mailing Address - State:AR
Mailing Address - Zip Code:72416-7661
Mailing Address - Country:US
Mailing Address - Phone:870-926-9259
Mailing Address - Fax:
Practice Address - Street 1:260 COUNTY ROAD 375
Practice Address - Street 2:
Practice Address - City:BONO
Practice Address - State:AR
Practice Address - Zip Code:72416-7661
Practice Address - Country:US
Practice Address - Phone:870-926-9259
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1619507324Medicaid