Basic Information
| Provider Information | |||||||||
| NPI: | 1225539208 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELMER | ||||||||
| FirstName: | LEA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MED, BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2423 HOOVER AVE | ||||||||
| Address2: | |||||||||
| City: | NATIONAL CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919506619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6197959925 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2423 HOOVER AVE | ||||||||
| Address2: | |||||||||
| City: | NATIONAL CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919506619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6197959925 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2018 | ||||||||
| LastUpdateDate: | 04/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 103K00000X | 1-21-48595 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1-21-48595 | 01 | CA | BACB | OTHER |