Healthcare Provider Details

I. General information

NPI: 1184495020
Provider Name (Legal Business Name): OMOTO ABA CONSULTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2024
Last Update Date: 01/10/2024
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5111 DIANE AVE
SAN DIEGO CA
92117-1356
US

IV. Provider business mailing address

3952D CLAIREMONT MESA BLVD # 387
SAN DIEGO CA
92117-2714
US

V. Phone/Fax

Practice location:
  • Phone: 916-549-2244
  • Fax:
Mailing address:
  • Phone: 619-215-1949
  • 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

VIII. Authorized Official

Name: MARTIN JASON OMOTO
Title or Position: EXECUTIVE DIRECTOR
Credential: MS, BCBA
Phone: 619-215-1949