Provider Demographics
NPI:1588034433
Name:VELLELLA, TARA (BCBA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:VELLELLA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:378 FOWLING ST
Mailing Address - Street 2:
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-7730
Mailing Address - Country:US
Mailing Address - Phone:651-285-2818
Mailing Address - Fax:
Practice Address - Street 1:3645 CARDIFF AVE
Practice Address - Street 2:# 304
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-7800
Practice Address - Country:US
Practice Address - Phone:310-821-0963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-15-19978103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst