Healthcare Provider Details

I. General information

NPI: 1538832548
Provider Name (Legal Business Name): BEHAVIOR ALL-STARS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2021
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 CAMINO DEL RIO S STE 200
SAN DIEGO CA
92108-4016
US

IV. Provider business mailing address

9257 LAKE MURRAY BLVD UNIT D
SAN DIEGO CA
92119-1400
US

V. Phone/Fax

Practice location:
  • Phone: 888-616-0864
  • Fax: 888-616-0864
Mailing address:
  • Phone: 888-616-0864
  • Fax: 888-616-0864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: KIRSTIN HALL
Title or Position: FOUNDER/EXECUTIVE DIRECTOR
Credential: BCBA
Phone: 888-616-0864