=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083334221
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEHAVIOR CLUB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2022
-----------------------------------------------------
Last Update Date | 08/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4961 ANDERSON WAY
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83687-8477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-907-4038
-----------------------------------------------------
Fax | 208-992-0246
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4961 ANDERSON WAY
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83687-8477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-245-6291
-----------------------------------------------------
Fax | 208-992-0246
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, BCBA
-----------------------------------------------------
Name | DR. SARAH LAMANA
-----------------------------------------------------
Credential | DHSC, BCBA
-----------------------------------------------------
Telephone | 208-907-4038
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------