MEDICARE: OPENING MINDS, 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

General Provider Information

NPI Number	:	1982288676
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPENING MINDS, INC.

Provider Business Mailing Address
First Line	:	6166 DILL CT
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95215-1003
Country	:	US
Telephone Number	:	209-636-3917
Fax Number	:

Provider Business Practice Location Address
First Line	:	6166 DILL CT
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95215-1003
Country	:	US
Telephone Number	:	209-227-0544
Fax Number	:

Authorized Official
Title or Position	:	BUSINESS SERVICES MANAGER
Name	:	MALY BOONSALAT
Credential	:
Telephone Number	:	209-616-9960

Provider Enumeration Date	:	05/08/2021
Last Update Date	:	08/12/2021

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Directions to “OPENING MINDS, INC. ” Practice Location

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