Healthcare Provider Details

I. General information

NPI: 1760911184
Provider Name (Legal Business Name): COLLABORATIVE PARTNERS FOR SUCCESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3472 TULANE AVENUE
LONG BEACH CA
90808
US

IV. Provider business mailing address

3472 TULANE AVE
LONG BEACH CA
90808-2654
US

V. Phone/Fax

Practice location:
  • Phone: 310-529-0301
  • Fax: 562-429-2365
Mailing address:
  • Phone: 310-529-0301
  • Fax: 562-429-2365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-09-5819
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number20198
License Number StateCA

VIII. Authorized Official

Name: MRS. VANESSA MICHELLE SMITH
Title or Position: DIRECTOR OF CLINICAL SERVICES
Credential: BCBA
Phone: 310-529-0301