=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497292965
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAY ABA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2017
-----------------------------------------------------
Last Update Date | 01/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3331 BRITTAN AVE APT. 8
-----------------------------------------------------
City | SAN CARLOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94070-3438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-494-8897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3331 BRITTAN AVE APT. 8
-----------------------------------------------------
City | SAN CARLOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94070-3438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-494-8897
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-FOUNDER
-----------------------------------------------------
Name | MISS LEAH C WOOD
-----------------------------------------------------
Credential | M.S., BCBA
-----------------------------------------------------
Telephone | 502-494-8897
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-13-13782
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------