MEDICARE: COLLEGE LIVING EXPERIENCE

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	1-01-0418	CA

General Provider Information

NPI Number	:	1689981714
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLEGE LIVING EXPERIENCE

Provider Business Mailing Address
First Line	:	2183 FAIRVIEW RD
Second Line	:	SUITE 101
City	:	COSTA MESA
State	:	CA
Zip	:	92627-5663
Country	:	US
Telephone Number	:	949-270-1234
Fax Number	:	949-270-1240

Provider Business Practice Location Address
First Line	:	25 SPECTRUM POINTE DR
Second Line	:	SUITE 405
City	:	LAKE FOREST
State	:	CA
Zip	:	92630-2276
Country	:	US
Telephone Number	:	949-939-8032
Fax Number	:	949-457-1347

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. ERICA R HOLDING
Credential	:	BCBA-D
Telephone Number	:	949-270-1233

Provider Enumeration Date	:	09/10/2010
Last Update Date	:	03/09/2012

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