MEDICARE: FULL HOUSE THERAPY, INC.

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11212270	OTHER	CA	BEHAVIORAL HEALTH

General Provider Information

NPI Number	:	1518666361
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULL HOUSE THERAPY, INC.

Provider Business Mailing Address
First Line	:	7828 BELLAIRE AVE
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91605-2116
Country	:	US
Telephone Number	:	818-939-2471
Fax Number	:

Provider Business Practice Location Address
First Line	:	7828 BELLAIRE AVE
Second Line	:
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91605-2116
Country	:	US
Telephone Number	:	818-939-2471
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MARAL YERETSYAN
Credential	:
Telephone Number	:	818-939-2471

Provider Enumeration Date	:	03/01/2023
Last Update Date	:	03/01/2023

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