MEDICARE: BUILDING SUCCESSFUL TRANSITIONS

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	PSB 33492	CA

General Provider Information

NPI Number	:	1326393687
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BUILDING SUCCESSFUL TRANSITIONS

Provider Business Mailing Address
First Line	:	12810 ARMINTA ST
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91605-2018
Country	:	US
Telephone Number	:	818-761-6617
Fax Number	:	818-761-6617

Provider Business Practice Location Address
First Line	:	12810 ARMINTA ST
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91605-2018
Country	:	US
Telephone Number	:	818-761-6617
Fax Number	:	818-761-6617

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DR. MARY M FALLIE
Credential	:
Telephone Number	:	818-761-6617

Provider Enumeration Date	:	07/23/2012
Last Update Date	:	07/23/2012

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