Healthcare Provider Details

I. General information

NPI: 1750204822
Provider Name (Legal Business Name): COREBRIDGE ABA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 E GLENOAKS BLVD STE 101
GLENDALE CA
91207-2096
US

IV. Provider business mailing address

333 E GLENOAKS BLVD STE 101
GLENDALE CA
91207-2096
US

V. Phone/Fax

Practice location:
  • Phone: 323-533-3777
  • Fax:
Mailing address:
  • Phone: 323-533-3777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIM MITCHELL POTTER
Title or Position: CONSUTANT
Credential: BCBA
Phone: 201-978-3815