Healthcare Provider Details

I. General information

NPI: 1992205165
Provider Name (Legal Business Name): JEREMY MONSANTO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2018
Last Update Date: 02/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629 PHOENIX DRIVE STE 150
VIRGINIA BEACH VA
23452
US

IV. Provider business mailing address

21600 OXNARD ST STE 1800
WOODLAND HILLS CA
91367
US

V. Phone/Fax

Practice location:
  • Phone: 757-837-0761
  • Fax:
Mailing address:
  • Phone: 818-345-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: