Healthcare Provider Details

I. General information

NPI: 1568928349
Provider Name (Legal Business Name): VIDA FOR AUTISM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2019
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 LANKERSHIM BLVD STE 500
NORTH HOLLYWOOD CA
91601-3187
US

IV. Provider business mailing address

5250 LANKERSHIM BLVD STE 500
NORTH HOLLYWOOD CA
91601-3187
US

V. Phone/Fax

Practice location:
  • Phone: 818-350-3839
  • Fax:
Mailing address:
  • Phone: 818-350-3839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EDWIN ALBERTO CRUZ
Title or Position: OWNER
Credential: BCBA
Phone: 323-388-6178