Provider Demographics
NPI:1033593397
Name:BEHAVIORAL SUPPORT PARTNERSHIP
Entity Type:Organization
Organization Name:BEHAVIORAL SUPPORT PARTNERSHIP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CASE SUPERVISOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MA, BCBA
Authorized Official - Phone:818-304-1313
Mailing Address - Street 1:522 WYCLIFFE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-1213
Mailing Address - Country:US
Mailing Address - Phone:818-304-1313
Mailing Address - Fax:
Practice Address - Street 1:12443 LEWIS ST
Practice Address - Street 2:SUITE 201
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4650
Practice Address - Country:US
Practice Address - Phone:714-748-4440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-15-18868103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty