Healthcare Provider Details

I. General information

NPI: 1255073789
Provider Name (Legal Business Name): IMPACT BEHAVIOR ANALYSIS AND SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4713 DELLA ROBIA CT
FAIR OAKS CA
95628-6141
US

IV. Provider business mailing address

4713 DELLA ROBIA CT
FAIR OAKS CA
95628-6141
US

V. Phone/Fax

Practice location:
  • Phone: 916-687-1594
  • Fax:
Mailing address:
  • Phone: 916-261-2910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: KYLA LAVALLE
Title or Position: OWNER, BEHAVIOR ANALYST
Credential:
Phone: 916-261-2910