Provider Demographics
NPI:1114663515
Name:LA RAIZ BEHAVIORAL SOLUTIONS
Entity Type:Organization
Organization Name:LA RAIZ BEHAVIORAL SOLUTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIOS
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:818-749-2263
Mailing Address - Street 1:1812 W BURBANK BLVD # 7003
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-1315
Mailing Address - Country:US
Mailing Address - Phone:818-749-2263
Mailing Address - Fax:
Practice Address - Street 1:5239 HARMONY AVE APT 306
Practice Address - Street 2:
Practice Address - City:N HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-5536
Practice Address - Country:US
Practice Address - Phone:818-749-2263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-09
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1124584602Medicaid