Provider Demographics
NPI:1558975300
Name:EGUAVOEN, OSARIEMEN RAYMOND (BCBA: 1-21-53406)
Entity Type:Individual
Prefix:
First Name:OSARIEMEN
Middle Name:RAYMOND
Last Name:EGUAVOEN
Suffix:
Gender:M
Credentials:BCBA: 1-21-53406
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 CAMDEN AVE APT 303
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-0347
Mailing Address - Country:US
Mailing Address - Phone:909-241-4247
Mailing Address - Fax:
Practice Address - Street 1:1804 CAMDEN AVE APT 303
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-0347
Practice Address - Country:US
Practice Address - Phone:909-241-4247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-31
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0-20-11667106E00000X
CA00002434106S00000X
CA1-21-53406103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty