Provider Demographics
NPI:1396251302
Name:LOUDEN, MICHELLE (BCBA-1-19-36893)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LOUDEN
Suffix:
Gender:F
Credentials:BCBA-1-19-36893
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11665 AVENA PL STE 204
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-2428
Mailing Address - Country:US
Mailing Address - Phone:760-349-4200
Mailing Address - Fax:
Practice Address - Street 1:11665 AVENA PL STE 204
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2428
Practice Address - Country:US
Practice Address - Phone:760-349-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-28
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-19-36893103K00000X
CARBT-15-00447106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst