Healthcare Provider Details

I. General information

NPI: 1780978858
Provider Name (Legal Business Name): FOOTPRINTS BEHAVIORAL INTERVENTIONS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 CARNEGIE AVE SUITE 1-C
SANTA ANA CA
92705-5504
US

IV. Provider business mailing address

1901 CARNEGIE AVE STE 1C
SANTA ANA CA
92705-5504
US

V. Phone/Fax

Practice location:
  • Phone: 714-848-8319
  • Fax: 714-596-6274
Mailing address:
  • Phone: 714-855-8895
  • Fax: 714-596-6274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number1052376
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1052376
License Number StateCA
# 7
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number1052376
License Number StateCA

VIII. Authorized Official

Name: MRS. HUONG DIEM NGUYEN
Title or Position: DIRECTOR OF OPERATIONS
Credential: MA
Phone: 714-855-8895