Basic Information
Provider Information | |||||||||
NPI: | 1770114944 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VIZCAINO | ||||||||
FirstName: | VIANCA | ||||||||
MiddleName: | CLAUDETTE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VIZCAINO | ||||||||
OtherFirstName: | BIANCA | ||||||||
OtherMiddleName: | CLAUDETTE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 21600 OXNARD ST STE 1800 | ||||||||
Address2: |   | ||||||||
City: | WOODLAND HILLS | ||||||||
State: | CA | ||||||||
PostalCode: | 913677807 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8183452345 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4322 WILSHIRE BLVD STE 104 | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900103737 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3238794951 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/28/2020 | ||||||||
LastUpdateDate: | 01/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/28/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X |   |   | Y |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
No ID Information.