MEDICARE: COASTAL BLOOM BEHAVIOR LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1124957824
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL BLOOM BEHAVIOR LLC

Provider Business Mailing Address
First Line	:	2955 CAMINO CALANDRIA
Second Line	:
City	:	THOUSAND OAKS
State	:	CA
Zip	:	91360-4532
Country	:	US
Telephone Number	:	805-870-9600
Fax Number	:	805-870-8159

Provider Business Practice Location Address
First Line	:	2955 CAMINO CALANDRIA
Second Line	:
City	:	THOUSAND OAKS
State	:	CA
Zip	:	91360-4532
Country	:	US
Telephone Number	:	805-870-9600
Fax Number	:	805-870-8159

Authorized Official
Title or Position	:	OWNER
Name	:	HANNAH JOSIE SANDOVAL
Credential	:	BCBA
Telephone Number	:	805-870-9600

Provider Enumeration Date	:	05/18/2026
Last Update Date	:	05/18/2026

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