Provider Demographics
NPI:1356016539
Name:SOURCE 1 BEHAVIORAL SERVICES, LLC
Entity Type:Organization
Organization Name:SOURCE 1 BEHAVIORAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:562-708-7639
Mailing Address - Street 1:222 W 6TH ST STE 400
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3345
Mailing Address - Country:US
Mailing Address - Phone:562-708-7639
Mailing Address - Fax:
Practice Address - Street 1:222 W 6TH ST STE 400
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3345
Practice Address - Country:US
Practice Address - Phone:562-708-7639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No251S00000XAgenciesCommunity/Behavioral Health