Healthcare Provider Details

I. General information

NPI: 1487920054
Provider Name (Legal Business Name): INSTITUTE FOR APPLIED BEHAVIOR ANALYSIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 03/31/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5777 W CENTURY BLVD STE 675
LOS ANGELES CA
90045-5632
US

IV. Provider business mailing address

5777 W CENTURY BLVD STE 675
LOS ANGELES CA
90045-5632
US

V. Phone/Fax

Practice location:
  • Phone: 310-649-0499
  • Fax:
Mailing address:
  • Phone: 310-649-0499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY5115
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY24318
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-01-0612
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-09-6511
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-11-7967
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-11-8158
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-02-0940
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name: SARA ELIZABETH BLACK
Title or Position: CEO
Credential:
Phone: 310-649-0499