Healthcare Provider Details

I. General information

NPI: 1942623749
Provider Name (Legal Business Name): BRAIN BASED BEHAVIOR CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2014
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4588 PERALTA BLVD STE 7
FREMONT CA
94536-5757
US

IV. Provider business mailing address

4588 PERALTA BLVD STE 7
FREMONT CA
94536-5757
US

V. Phone/Fax

Practice location:
  • Phone: 510-972-1030
  • Fax: 510-793-6399
Mailing address:
  • Phone: 510-972-1030
  • Fax: 510-793-6399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number11212648
License Number StateCA

VIII. Authorized Official

Name: MICHAEL SLONE
Title or Position: ABA THERAPIST
Credential: BCBA-D
Phone: 510-972-1030