Provider Demographics
NPI:1558629832
Name:O' GORMANTRIMBATH, REBECCA MARION (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARION
Last Name:O' GORMANTRIMBATH
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 HOLLISTER AVE
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-2512
Mailing Address - Country:US
Mailing Address - Phone:269-352-3660
Mailing Address - Fax:
Practice Address - Street 1:370 HOLLISTER AVE
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-2512
Practice Address - Country:US
Practice Address - Phone:269-352-3660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-24
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-09-5707103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1-09-5707OtherBCBA CERTIFICATE