MEDICARE: SHANTAL ROMAN

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1326561911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANTAL ROMAN

Provider Business Mailing Address
First Line	:	2080 N TUSTIN AVE STE B
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92705-7875
Country	:	US
Telephone Number	:	855-581-0100
Fax Number	:

Provider Business Practice Location Address
First Line	:	2033 GATEWAY PL FL 5
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95110-3709
Country	:	US
Telephone Number	:	855-581-0100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2017
Last Update Date	:	07/20/2020

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Directions to “ SHANTAL ROMAN ” Practice Location

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