Healthcare Provider Details

I. General information

NPI: 1780937235
Provider Name (Legal Business Name): AVITA NOVA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2012
Last Update Date: 10/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 BELLECOUR WAY
LAKE FOREST CA
92630-7944
US

IV. Provider business mailing address

1202 BELLECOUR WAY
LAKE FOREST CA
92630-7944
US

V. Phone/Fax

Practice location:
  • Phone: 949-939-8032
  • Fax: 949-525-4759
Mailing address:
  • Phone: 949-939-8032
  • Fax: 949-525-4759

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: ERICA R. HOLDING
Title or Position: OWNER
Credential: PH.D., BCBA
Phone: 949-939-8032