=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750081253
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FORTE BEHAVIORAL HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2023
-----------------------------------------------------
Last Update Date | 03/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2139 GLENDON AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025-6325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-324-1557
-----------------------------------------------------
Fax | 888-260-1621
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2139 GLENDON AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025-6325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-324-1557
-----------------------------------------------------
Fax | 888-260-1621
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | SHANE SHAFFER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-562-7363
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106E00000X
-----------------------------------------------------
Taxonomy Name | Assistant Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------