MEDICARE: CREATIVE BEHAVIOR INTERVENTIONS

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	103TB0200X	Cognitive & Behavioral Psychologist	PSY22024	CA
2	251C00000X	Developmentally Disabled Services Day Training Agency	1-07-3777	CA
3	103K00000X	Behavior Analyst	1-07-3777	CA

General Provider Information

NPI Number	:	1750650933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CREATIVE BEHAVIOR INTERVENTIONS

Provider Business Mailing Address
First Line	:	3002 DOW AVE
Second Line	:	SUITE 520
City	:	TUSTIN
State	:	CA
Zip	:	92780-7233
Country	:	US
Telephone Number	:	949-861-1580
Fax Number	:	949-328-7689

Provider Business Practice Location Address
First Line	:	3002 DOW AVE
Second Line	:	SUITE 520
City	:	TUSTIN
State	:	CA
Zip	:	92780-7233
Country	:	US
Telephone Number	:	949-861-1580
Fax Number	:	949-328-7689

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DENISE MARIE ECKMAN
Credential	:	PSY.D., BCBA-D
Telephone Number	:	949-861-1580

Provider Enumeration Date	:	12/19/2011
Last Update Date	:	12/19/2011

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