Healthcare Provider Details

I. General information

NPI: 1528332012
Provider Name (Legal Business Name): MAVERICK EDUCATION & BEHAVIORAL SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2012
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7949 CALIFORNIA AVE STE 14
FAIR OAKS CA
95628-7156
US

IV. Provider business mailing address

7949 CALIFORNIA AVE STE 14
FAIR OAKS CA
95628-7156
US

V. Phone/Fax

Practice location:
  • Phone: 916-863-7949
  • Fax:
Mailing address:
  • Phone: 916-863-7949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1000030
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number1000030
License Number StateCA

VIII. Authorized Official

Name: DAWN MONTGOMERY
Title or Position: CEO/OWNER
Credential: M.S., B.C.B.A.
Phone: 916-983-7949