Healthcare Provider Details

I. General information

NPI: 1154702462
Provider Name (Legal Business Name): FUNCTIONAL BEHAVIORAL INTERVENTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GRACE AVE
LA HABRA CA
90631-6846
US

IV. Provider business mailing address

100 GRACE AVE
LA HABRA CA
90631-6846
US

V. Phone/Fax

Practice location:
  • Phone: 562-236-7908
  • Fax:
Mailing address:
  • Phone: 562-236-7908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. AMANDA RENEE PEREZ
Title or Position: CCO, VICE PRESIDENT
Credential: M.A., M.A., B.C.B.A.
Phone: 562-236-7908