Healthcare Provider Details

I. General information

NPI: 1043748940
Provider Name (Legal Business Name): OLUMUYIWA FAGBOHUN ABA SPECIALIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 05/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 S MYRTLE AVE # 100
MONROVIA CA
91016-3406
US

IV. Provider business mailing address

612 S MYRTLE AVE # 100
MONROVIA CA
91016-3406
US

V. Phone/Fax

Practice location:
  • Phone: 909-268-8955
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: