Basic Information
| Provider Information | |||||||||
| NPI: | 1730590365 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAVIS | ||||||||
| FirstName: | BRANDI | ||||||||
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| Credential: | M.ED., BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40485 MURRIETA HOT SPRINGS RD | ||||||||
| Address2: | B-4, #146 | ||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925636436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9518134034 | ||||||||
| FaxNumber: | 9518134035 | ||||||||
| Practice Location | |||||||||
| Address1: | 41951 REMINGTON AVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9518134034 | ||||||||
| FaxNumber: | 9518134035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2014 | ||||||||
| LastUpdateDate: | 07/09/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-14-15639 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.