Provider Demographics
NPI:1356828909
Name:BALDERRAMA, AKETZALI (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:AKETZALI
Middle Name:
Last Name:BALDERRAMA
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6232 N 7TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-1850
Mailing Address - Country:US
Mailing Address - Phone:623-693-2954
Mailing Address - Fax:
Practice Address - Street 1:10150 W DESERT RIVER BLVD STE 160
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85307-3010
Practice Address - Country:US
Practice Address - Phone:623-693-2954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRBT-18-60729106S00000X
AZBEH-000664103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician