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General NPI Number Information
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NPI Number | 1942623749
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Entity Type | Organization
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Legal Business Name | BRAIN BASED BEHAVIOR CENTER, INC.
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Dates
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Enumeration Date | 01/29/2014
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Last Update Date | 01/29/2014
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Provider Practice Location Address
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Address Line | 4588 PERALTA BLVD STE 7
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City | FREMONT
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State | CA
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Zip | 94536-5757
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Country | US
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Telephone | 510-972-1030
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Fax | 510-793-6399
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Provider Business Mailing Address
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Address Line | 4588 PERALTA BLVD STE 7
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City | FREMONT
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State | CA
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Zip | 94536-5757
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Country | US
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Telephone | 510-972-1030
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Fax | 510-793-6399
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Authorized Official
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Title or Position | ABA THERAPIST
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Name | MICHAEL SLONE
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Credential | BCBA-D
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Telephone | 510-972-1030
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 11212648
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License Number State | CA
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