=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295551141
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BACK TO BASICS BEHAVIOR SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2024
-----------------------------------------------------
Last Update Date | 04/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5101 SANTA MONICA BLVD STE 8
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90029-2480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-762-5006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5101 SANTA MONICA BOULEVARD STE 8 PMB 1393
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-762-5006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | LAURA EILEEN LAMANTIA
-----------------------------------------------------
Credential | BCBA
-----------------------------------------------------
Telephone | 323-762-5006
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------