=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912597949
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IVANA JURIC BCBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2021
-----------------------------------------------------
Last Update Date | 03/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23811 WASHINGTON AVE
-----------------------------------------------------
City | MURRIETA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92562-2275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-252-5677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27679 SONORA CIR
-----------------------------------------------------
City | TEMECULA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92591-2838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-265-1156
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-22-20778
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------