Healthcare Provider Details

I. General information

NPI: 1821623018
Provider Name (Legal Business Name): APPLIED BEHAVIOR AUTISM CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2020
Last Update Date: 04/17/2020
Certification Date: 04/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24081 SANDY GLADE AVE
MORENO VALLEY CA
92557-5529
US

IV. Provider business mailing address

5838 TOSCANA TRCE
ROUND ROCK TX
78665-4402
US

V. Phone/Fax

Practice location:
  • Phone: 916-869-2416
  • Fax: 512-572-8647
Mailing address:
  • Phone: 916-869-2416
  • 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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHAMICA MORTON
Title or Position: OWNER
Credential: M.S., BCBA, LBA
Phone: 916-869-2416