=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457784613
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BERTA CECILIA VASQUEZ M.A, BCBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2013
-----------------------------------------------------
Last Update Date | 04/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4221 WILSHIRE BLVD STE 300
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90010-3512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-428-3223
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12004 VANOWEN ST APT 9
-----------------------------------------------------
City | NORTH HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91605-6916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-255-8334
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------