Provider Demographics
NPI:1194493049
Name:GO BEHAVIORAL LLC
Entity type:Organization
Organization Name:GO BEHAVIORAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUSTAFA
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:321-830-0870
Mailing Address - Street 1:5460 W MISSION AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-5098
Mailing Address - Country:US
Mailing Address - Phone:321-830-0870
Mailing Address - Fax:
Practice Address - Street 1:5460 W MISSION AVE STE 100
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-5098
Practice Address - Country:US
Practice Address - Phone:321-830-0870
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-03
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities