Healthcare Provider Details

I. General information

NPI: 1558975300
Provider Name (Legal Business Name): OSARIEMEN RAYMOND EGUAVOEN BCBA: 1-21-53406
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2020
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2338 W ROYAL PALM RD STE J
PHOENIX AZ
85021-9339
US

IV. Provider business mailing address

11953 DOROTHY ST APT 3
LOS ANGELES CA
90049-5310
US

V. Phone/Fax

Practice location:
  • Phone: 909-241-4247
  • Fax:
Mailing address:
  • Phone: 909-241-4247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-53406
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-20-11667
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number00002434
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: