Healthcare Provider Details

I. General information

NPI: 1619485083
Provider Name (Legal Business Name): JOANNA ALICIA HERRERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17595 ALMAHURST ST STE 100A
CITY OF INDUSTRY CA
91748
US

IV. Provider business mailing address

16782 VON KARMAN AVE STE 11
IRVINE CA
92606-2417
US

V. Phone/Fax

Practice location:
  • Phone: 855-223-7123
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-18-32996
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: