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General NPI Number Information
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NPI Number | 1740153691
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Entity Type | Organization
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Legal Business Name | LAKESIDE ABA AZ LLC
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Dates
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Enumeration Date | 09/26/2025
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Last Update Date | 09/26/2025
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Provider Practice Location Address
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Address Line | 4539 N 22ND ST STE R
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City | PHOENIX
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State | AZ
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Zip | 85016-4639
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Country | US
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Telephone | 410-357-1840
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Fax |
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Provider Business Mailing Address
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Address Line | 1500 S DOHENY DR
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City | LOS ANGELES
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State | CA
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Zip | 90035-3211
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. CHARLES WILLIAMS
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Credential | PSYD
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Telephone | 213-435-9423
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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