Healthcare Provider Details

I. General information

NPI: 1598298622
Provider Name (Legal Business Name): LYNETTE ELIZABETH WYCKOFF MA, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3641 VISTA VIEW CIR
SANTA CLARA UT
84765-5655
US

IV. Provider business mailing address

16782 VON KARMAN AVE STE 11
IRVINE CA
92606-2417
US

V. Phone/Fax

Practice location:
  • Phone: 435-767-7929
  • Fax: 435-710-1007
Mailing address:
  • Phone: 949-833-2237
  • Fax: 949-457-9213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-17-25329
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number13431914-2506
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: