Provider Demographics
NPI:1679093009
Name:DAISY MAE ABA, LLC
Entity type:Organization
Organization Name:DAISY MAE ABA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TANIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, BCBA, LBA
Authorized Official - Phone:757-302-8877
Mailing Address - Street 1:3212 CLEARCREEK RD.
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434
Mailing Address - Country:US
Mailing Address - Phone:757-302-8877
Mailing Address - Fax:850-807-5028
Practice Address - Street 1:3212 CLEARCREEK RD.
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434
Practice Address - Country:US
Practice Address - Phone:757-302-8877
Practice Address - Fax:850-807-5028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-27
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty