=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306309430
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHAPING BEHAVIORAL PATHWAYS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2019
-----------------------------------------------------
Last Update Date | 04/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 164 1/2 N AVENUE 23
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90031-1802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-268-4235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 164 1/2 N AVENUE 23
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90031-1802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-268-4235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | JENNIFER MARIE GUZMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 626-714-1228
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------