Provider Demographics
NPI:1710423835
Name:GIDLUND, RENITA (BCBA)
Entity Type:Individual
Prefix:
First Name:RENITA
Middle Name:
Last Name:GIDLUND
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 1:3978 SORRENTO VALLEY BLVD
Mailing Address - Street 2:#100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1436
Mailing Address - Country:US
Mailing Address - Phone:858-353-7723
Mailing Address - Fax:
Practice Address - Street 1:3978 SORRENTO VALLEY BLVD
Practice Address - Street 2:100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1436
Practice Address - Country:US
Practice Address - Phone:858-353-7723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-16-24594103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1-16-24594OtherBEHAVIOR ANALYST CERTIFICATION BOARD