Healthcare Provider Details

I. General information

NPI: 1114542719
Provider Name (Legal Business Name): IRINA LEONIDOVNA GONTAR BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7806 UPLANDS WAY
CITRUS HEIGHTS CA
95610-7567
US

IV. Provider business mailing address

18726 S WESTERN AVE
GARDENA CA
90248-3813
US

V. Phone/Fax

Practice location:
  • Phone: 310-856-0800
  • Fax:
Mailing address:
  • Phone: 310-856-0800
  • Fax: 855-568-2494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-77334
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: