MEDICARE: BACK TO BASICS BEHAVIOR SERVICES, 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	:	1295551141
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK TO BASICS BEHAVIOR SERVICES, LLC

Provider Business Mailing Address
First Line	:	5101 SANTA MONICA BOULEVARD
Second Line	:	STE 8 PMB 1393
City	:	LOS ANGELES
State	:	CA
Zip	:	90029
Country	:	US
Telephone Number	:	323-762-5006
Fax Number	:

Provider Business Practice Location Address
First Line	:	5101 SANTA MONICA BLVD STE 8
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-2480
Country	:	US
Telephone Number	:	323-762-5006
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	LAURA EILEEN LAMANTIA
Credential	:	BCBA
Telephone Number	:	323-762-5006

Provider Enumeration Date	:	11/25/2024
Last Update Date	:	04/10/2025

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