Healthcare Provider Details

I. General information

NPI: 1598394223
Provider Name (Legal Business Name): SAN DIEGO APPLIED BEHAVIOR ANALYSIS , LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2020
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 SPRING STREET SUITE 104
LA MESA CA
91942
US

IV. Provider business mailing address

8030 LA MESA BLVD STE 25
LA MESA CA
91942-0335
US

V. Phone/Fax

Practice location:
  • Phone: 619-782-0700
  • Fax: 619-782-0710
Mailing address:
  • Phone: 619-782-0700
  • Fax: 619-782-0710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SHANNA DOLAN
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 951-259-4060