Provider Demographics
NPI:1548814551
Name:ADVANCE ABA , LLC
Entity type:Organization
Organization Name:ADVANCE ABA , LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:ABDI
Authorized Official - Middle Name:
Authorized Official - Last Name:MURIDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-245-4778
Mailing Address - Street 1:PO BOX 12279
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-2279
Mailing Address - Country:US
Mailing Address - Phone:517-245-4778
Mailing Address - Fax:517-698-8223
Practice Address - Street 1:2021 MONROE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2926
Practice Address - Country:US
Practice Address - Phone:517-245-4778
Practice Address - Fax:517-698-8223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-29
Last Update Date:2024-06-07
Deactivation Date:2022-08-17
Deactivation Code:
Reactivation Date:2022-10-03
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM630758029234OtherSTATE OF MI DRIVER'S LICENSE
MIV340261067770OtherSTATE OF MI DRIVER'S LICENSE