Healthcare Provider Details

I. General information

NPI: 1851710479
Provider Name (Legal Business Name): FOOTPRINTS BEHAVIORAL INTERVENTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11037 WARNER AVE SUITE 339
FOUNTAIN VALLEY CA
92708-4007
US

IV. Provider business mailing address

11037 WARNER AVE SUITE 339
FOUNTAIN VALLEY CA
92708-4007
US

V. Phone/Fax

Practice location:
  • Phone: 800-273-4292
  • Fax: 949-253-4627
Mailing address:
  • Phone: 800-273-4292
  • Fax: 949-253-4627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LIN CONNOR
Title or Position: PROVIDER RELATIONS COORDINATOR
Credential: LPN
Phone: 50329853589