Basic Information
| Provider Information | |||||||||
| NPI: | 1265773444 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WASANO | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A., BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2560 9TH ST STE 219 | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947102557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106659700 | ||||||||
| FaxNumber: | 5106659400 | ||||||||
| Practice Location | |||||||||
| Address1: | 2560 9TH ST STE 219 | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947102557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106659700 | ||||||||
| FaxNumber: | 5106659400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2013 | ||||||||
| LastUpdateDate: | 03/12/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1-07-3310 | 01 | BCBA | OTHER |