Provider Demographics
NPI:1053034231
Name:SUPPORTIVE CARE ABA VA LLC
Entity type:Organization
Organization Name:SUPPORTIVE CARE ABA VA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KESHERIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-936-1240
Mailing Address - Street 1:1765 GREENSBORO STATION PL
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-3467
Mailing Address - Country:US
Mailing Address - Phone:317-936-1240
Mailing Address - Fax:317-936-1241
Practice Address - Street 1:1765 GREENSBORO STATION PL
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-3467
Practice Address - Country:US
Practice Address - Phone:317-936-1240
Practice Address - Fax:317-936-1241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-22
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty