MEDICARE: FOOTPRINTS BEHAVIORAL INTERVENTIONS, 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	251S00000X	Community/Behavioral Health Agency	1052376	CA
2	106S00000X	Behavior Technician
3	225X00000X	Occupational Therapist
4	235Z00000X	Speech-Language Pathologist
5	251C00000X	Developmentally Disabled Services Day Training Agency	1052376	CA
6	106E00000X	Assistant Behavior Analyst
7	252Y00000X	Early Intervention Provider Agency	1052376	CA

General Provider Information

NPI Number	:	1780978858
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOTPRINTS BEHAVIORAL INTERVENTIONS, INC.

Provider Business Mailing Address
First Line	:	1901 CARNEGIE AVE STE 1C
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92705-5504
Country	:	US
Telephone Number	:	714-855-8895
Fax Number	:	714-596-6274

Provider Business Practice Location Address
First Line	:	1901 CARNEGIE AVE
Second Line	:	SUITE 1-C
City	:	SANTA ANA
State	:	CA
Zip	:	92705-5504
Country	:	US
Telephone Number	:	714-848-8319
Fax Number	:	714-596-6274

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MRS. HUONG DIEM NGUYEN
Credential	:	MA
Telephone Number	:	714-855-8895

Provider Enumeration Date	:	06/06/2011
Last Update Date	:	07/28/2020

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