Provider Demographics
NPI:1598401150
Name:KEIVANNIA, SHADY
Entity Type:Individual
Prefix:
First Name:SHADY
Middle Name:
Last Name:KEIVANNIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BEHAVIOR FRONTIERS, LLC
Mailing Address - Street 2:1100 W TOWN & COUNTRY RD, SUITE 1250
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868
Mailing Address - Country:US
Mailing Address - Phone:949-357-2556
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:BEHAVIOR FRONTIERS, LLC
Practice Address - Street 2:1100 W TOWN & COUNTRY RD, SUIT
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868
Practice Address - Country:US
Practice Address - Phone:949-357-2556
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9495007838X0000106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician