Healthcare Provider Details

I. General information

NPI: 1356109649
Provider Name (Legal Business Name): JANET GUADALUPE BRISENO MACIAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1274 CENTER COURT DR STE 211
COVINA CA
91724-3668
US

IV. Provider business mailing address

1274 CENTER COURT DR STE 211
COVINA CA
91724-3668
US

V. Phone/Fax

Practice location:
  • Phone: 626-339-4999
  • Fax:
Mailing address:
  • Phone: 626-339-4999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: