Healthcare Provider Details

I. General information

NPI: 1144598467
Provider Name (Legal Business Name): ADVANCEMENT FOR BEHAVIORAL & EDUCATIONAL DEVELOPMENT & INTERVENTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2011
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 CENTENNIAL WAY
TUSTIN CA
92780-3714
US

IV. Provider business mailing address

315 CENTENNIAL WAY
TUSTIN CA
92780-3714
US

V. Phone/Fax

Practice location:
  • Phone: 949-250-1101
  • Fax: 949-250-1103
Mailing address:
  • Phone: 949-250-1101
  • Fax: 949-250-1103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-04-1559
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4039
License Number StateCA

VIII. Authorized Official

Name: RHONDA MARIE RIVAS
Title or Position: MANAGER OF ADMINISTRATIVE SERVICES
Credential:
Phone: 949-250-1101