Healthcare Provider Details

I. General information

NPI: 1649766619
Provider Name (Legal Business Name): MALLORY SHIRAZI BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2667 CAMINO DEL RIO S STE 102
SAN DIEGO CA
92108-3763
US

IV. Provider business mailing address

3110 CAMINO DEL RIO S
SAN DIEGO CA
92108-3812
US

V. Phone/Fax

Practice location:
  • Phone: 619-782-0700
  • Fax:
Mailing address:
  • Phone: 619-795-9925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-58477
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: