MEDICARE: MAKI KIDO 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	BCBA 1-13-13693	CA

General Provider Information

NPI Number	:	1710328570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAKI KIDO BCBA

Provider Business Mailing Address
First Line	:	PO BOX 33568
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92163-3568
Country	:	US
Telephone Number	:	855-223-7123
Fax Number	:	619-374-7134

Provider Business Practice Location Address
First Line	:	12465 LEWIS ST STE 102
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92840-4658
Country	:	US
Telephone Number	:	855-223-7123
Fax Number	:

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

Provider Enumeration Date	:	07/09/2013
Last Update Date	:	08/21/2024

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