Provider Demographics
NPI:1912498312
Name:FARDANESH, ERIKA (RBT)
Entity Type:Individual
Prefix:
First Name:ERIKA
Middle Name:
Last Name:FARDANESH
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:ERIKA
Other - Middle Name:
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 609001
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92160-9001
Mailing Address - Country:US
Mailing Address - Phone:619-528-4600
Mailing Address - Fax:619-528-4625
Practice Address - Street 1:1550 HOTEL CIR N STE 270
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2908
Practice Address - Country:US
Practice Address - Phone:619-814-4694
Practice Address - Fax:619-528-4625
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-22
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW416Medicaid