Healthcare Provider Details

I. General information

NPI: 1013858984
Provider Name (Legal Business Name): MY MIRACLE CHILD ABA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2026
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1144 N HOWARD ST
GLENDALE CA
91207-1747
US

IV. Provider business mailing address

1144 N HOWARD ST
GLENDALE CA
91207-1747
US

V. Phone/Fax

Practice location:
  • Phone: 323-896-9086
  • Fax:
Mailing address:
  • Phone:
  • 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: LISA YERETSIAN
Title or Position: CEO
Credential:
Phone: 323-896-9086