=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922372267
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEHAVIORAL SUPPORT CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2012
-----------------------------------------------------
Last Update Date | 05/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8546 BROADWAY ST BLDG C BLDG C SUITE 200
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78217-6376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-526-1806
-----------------------------------------------------
Fax | 210-547-7984
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8546 BROADWAY ST STE. 200
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78217-6376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-526-1806
-----------------------------------------------------
Fax | 210-547-7984
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. JOHNNY R. YBARRA
-----------------------------------------------------
Credential | LCDC, MAC, SAP, QASP
-----------------------------------------------------
Telephone | 210-526-1806
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | LCDC TX: 12124
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------