Healthcare Provider Details

I. General information

NPI: 1386191674
Provider Name (Legal Business Name): CARLY TYRELL BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2016
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 W ORANGEWOOD AVE STE 150
ORANGE CA
92868
US

IV. Provider business mailing address

4221 WILSHIRE BLVD STE 300A
LOS ANGELES CA
90010-3537
US

V. Phone/Fax

Practice location:
  • Phone: 888-428-3223
  • Fax: 323-866-1881
Mailing address:
  • Phone: 888-428-3223
  • Fax: 323-866-1881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-14-9971
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: