MEDICARE: MISS CRISTINA ELIZABETH GALLARDO BCBA

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	1-18-34159	CA

General Provider Information

NPI Number	:	1073087607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CRISTINA ELIZABETH GALLARDO BCBA

Provider Business Mailing Address
First Line	:	18726 S WESTERN AVE
Second Line	:
City	:	GARDENA
State	:	CA
Zip	:	90248-3813
Country	:	US
Telephone Number	:	310-856-0800
Fax Number	:	855-568-2494

Provider Business Practice Location Address
First Line	:	2670 N MAIN ST
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92705-6639
Country	:	US
Telephone Number	:	714-656-0354
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2019
Last Update Date	:	01/16/2019

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