MEDICARE: BALANCE BEHAVIOR THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1013613173
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALANCE BEHAVIOR THERAPY LLC

Provider Business Mailing Address
First Line	:	18472 MANNING DR
Second Line	:
City	:	TUSTIN
State	:	CA
Zip	:	92780-2236
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9013 HORSE HERD DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-3072
Country	:	US
Telephone Number	:	714-366-9444
Fax Number	:

Authorized Official
Title or Position	:	BOARD CERTIFIED BEHAVIOR ANALYST
Name	:	MRS. ARIEL E KELLAM
Credential	:	M.ED., BCBA
Telephone Number	:	714-366-9444

Provider Enumeration Date	:	01/31/2023
Last Update Date	:	01/31/2023

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