MEDICARE: CHILDRENS LEARNING CONNECTION, 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	BCBA 1-07-3352	CA
2	103K00000X	Behavior Analyst	BCBA 1-09-5316	CA
3	103K00000X	Behavior Analyst	1-09-5375	CA
4	103K00000X	Behavior Analyst	BCBA 1-03-1209	CA
5	2251P0200X	Pediatric Physical Therapist	PT 36283	CA
6	2251P0200X	Pediatric Physical Therapist	PT 37480	CA
7	225XP0200X	Pediatric Occupational Therapist	OT 8264	CA
8	225XP0200X	Pediatric Occupational Therapist	OT 11533	CA
9	235Z00000X	Speech-Language Pathologist	SP 11693	CA
10	235Z00000X	Speech-Language Pathologist	SP 15824	CA
11	235Z00000X	Speech-Language Pathologist	SP 15812	CA
12	235Z00000X	Speech-Language Pathologist	SP 14005	CA
13	235Z00000X	Speech-Language Pathologist	SP 10842	CA
14	235Z00000X	Speech-Language Pathologist	SP12005	CA

General Provider Information

NPI Number	:	1689723595
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDRENS LEARNING CONNECTION, LLC

Provider Business Mailing Address
First Line	:	505 N. BRAND BLVD
Second Line	:	SUITE 1000
City	:	GLENDALE
State	:	CA
Zip	:	91203
Country	:	US
Telephone Number	:	855-295-3276
Fax Number	:	818-241-6853

Provider Business Practice Location Address
First Line	:	5312 BOLSA AVE.
Second Line	:	STE. # 105
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92649
Country	:	US
Telephone Number	:	818-241-6780
Fax Number	:	818-241-6853

Authorized Official
Title or Position	:	CHEIF EXECUTIVE OFFICER
Name	:	JEFFERY WINTER
Credential	:
Telephone Number	:	818-241-6780

Provider Enumeration Date	:	01/09/2007
Last Update Date	:	12/07/2018

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