MEDICARE: MR. SHANE KEOLA NOBORU OKAMOTO BCBA, MED

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	1-22-62987

General Provider Information

NPI Number	:	1538949490
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SHANE KEOLA NOBORU OKAMOTO BCBA, MED

Provider Business Mailing Address
First Line	:	18257 ASTRO CT
Second Line	:
City	:	SANTA CLARITA
State	:	CA
Zip	:	91350-3265
Country	:	US
Telephone Number	:	661-388-0357
Fax Number	:

Provider Business Practice Location Address
First Line	:	18257 ASTRO CT
Second Line	:
City	:	SANTA CLARITA
State	:	CA
Zip	:	91350-3265
Country	:	US
Telephone Number	:	661-388-0357
Fax Number	:

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

Provider Enumeration Date	:	09/28/2023
Last Update Date	:	09/28/2023

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