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General NPI Number Information
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NPI Number | 1356016539
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Entity Type | Organization
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Legal Business Name | SOURCE 1 BEHAVIORAL SERVICES, LLC
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Dates
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Enumeration Date | 08/10/2021
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 222 W 6TH ST STE 400
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City | SAN PEDRO
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State | CA
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Zip | 90731-3345
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Country | US
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Telephone | 562-708-7639
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Fax |
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Provider Business Mailing Address
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Address Line | 222 W 6TH ST STE 400
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City | SAN PEDRO
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State | CA
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Zip | 90731-3345
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Country | US
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Telephone | 562-708-7639
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR/OWNER
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Name | DANIELLE MARIE BAKER
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Credential | BCBA
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Telephone | 562-708-7639
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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