Healthcare Provider Details

I. General information

NPI: 1891902292
Provider Name (Legal Business Name): RICHARD A. WOLDEMAR BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 STONERIDGE MALL RD STE 205
PLEASANTON CA
94588-3347
US

IV. Provider business mailing address

500 FAIRWAY DR STE 102
DEERFIELD BEACH FL
33441-1817
US

V. Phone/Fax

Practice location:
  • Phone: 877-418-2978
  • Fax: 877-500-2186
Mailing address:
  • Phone: 877-418-2978
  • Fax: 877-500-2186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-13-14527
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: