Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106S00000X | Behavior Technician | RBT-16-26500 | CA |
NPI | 1003353681 |
---|---|
Provider Name | Lisa Dimercurio |
First Address | Ontario, CA 91764-5030 |
Second Address | Ontario, CA 91764-5030 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/01/2017 |
Last Update Date | 20/01/2017 |