Healthcare Provider Details

I. General information

NPI: 1679926349
Provider Name (Legal Business Name): ADVANCED BEHAVIORAL LEARNING ENVIRONMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24522 AGUIRRE
MISSION VIEJO CA
92692
US

IV. Provider business mailing address

24522 AGUIRRE
MISSION VIEJO CA
92692
US

V. Phone/Fax

Practice location:
  • Phone: 949-441-9493
  • Fax:
Mailing address:
  • Phone: 949-441-9493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: KELLY BROOKS
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 949-441-9493