=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043673130
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH GARCIA M.S., BCBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2016
-----------------------------------------------------
Last Update Date | 04/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18726 S WESTERN AVE STE 408
-----------------------------------------------------
City | GARDENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90248-3858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-864-1593
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18726 S WESTERN AVE STE 408
-----------------------------------------------------
City | GARDENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90248-3858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-864-1593
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-16-21792
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------