Provider Demographics
NPI:1578230892
Name:LLKD21 LLC
Entity Type:Organization
Organization Name:LLKD21 LLC
Other - Org Name:TAILORED BEHAVIOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:310-767-6354
Mailing Address - Street 1:1230 ROSECRANS AVE STE 300
Mailing Address - Street 2:PMB #792
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-2494
Mailing Address - Country:US
Mailing Address - Phone:888-361-2660
Mailing Address - Fax:
Practice Address - Street 1:1230 ROSECRANS AVE STE 300
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-2494
Practice Address - Country:US
Practice Address - Phone:888-361-2660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-25
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency