Provider Demographics
NPI:1790157154
Name:BEHAVIORANALYSTSUPERVISOR
Entity Type:Organization
Organization Name:BEHAVIORANALYSTSUPERVISOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:VAN LAEKEN
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, LEP
Authorized Official - Phone:530-227-2883
Mailing Address - Street 1:809 MCCLOUD AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-9603
Mailing Address - Country:US
Mailing Address - Phone:530-227-2883
Mailing Address - Fax:
Practice Address - Street 1:809 MCCLOUD AVE
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-9603
Practice Address - Country:US
Practice Address - Phone:530-227-2883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-13-12972103K00000X
CALEP3635103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty