Provider Demographics
NPI:1750783890
Name:BEACON AUTISTIC SPECTRUM INDEPENDENCE CENTER- B.A.S.I.C.
Entity type:Organization
Organization Name:BEACON AUTISTIC SPECTRUM INDEPENDENCE CENTER- B.A.S.I.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:LANG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:714-288-4200
Mailing Address - Street 1:24 CENTERPOINTE DR
Mailing Address - Street 2:
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-1028
Mailing Address - Country:US
Mailing Address - Phone:714-288-4200
Mailing Address - Fax:714-707-4316
Practice Address - Street 1:24 CENTERPOINTE DR
Practice Address - Street 2:
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-1028
Practice Address - Country:US
Practice Address - Phone:714-288-4200
Practice Address - Fax:714-707-4316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12076103G00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty