MEDICARE: SANDRA IRYAMI BCBA

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	1-19-36196	CA

General Provider Information

NPI Number	:	1568010452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA IRYAMI BCBA

Provider Business Mailing Address
First Line	:	2265 S BEVERLY GLEN BLVD APT 206
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-2444
Country	:	US
Telephone Number	:	310-717-6564
Fax Number	:

Provider Business Practice Location Address
First Line	:	2265 S BEVERLY GLEN BLVD APT 206
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-2444
Country	:	US
Telephone Number	:	310-717-6564
Fax Number	:

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

Provider Enumeration Date	:	09/03/2019
Last Update Date	:	09/03/2019

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