=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154916633
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUNA BEHAVIORAL HEALTH TREATMENT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2021
-----------------------------------------------------
Last Update Date | 03/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5720 OWENSMOUTH AVE #168
-----------------------------------------------------
City | WOODLAND HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91367-4962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-461-4208
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5720 OWENSMOUTH AVE #168
-----------------------------------------------------
City | WOODLAND HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91367-4962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-461-4208
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MAHSA MESBAH HESARI
-----------------------------------------------------
Credential | BCBA
-----------------------------------------------------
Telephone | 818-461-4208
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------