Provider Demographics
NPI:1154830974
Name:DUTRA, VERONICA CHRISTINE (BCBA)
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:CHRISTINE
Last Name:DUTRA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:VERONICA
Other - Middle Name:CHRISTINE
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19019 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19019 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3253
Practice Address - Country:US
Practice Address - Phone:818-501-8352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-17-26724103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst