Provider Demographics
NPI:1699146472
Name:BOVINO, BRIAN (MA, BCBA)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:BOVINO
Suffix:
Gender:M
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3575 KENYON ST STE 102
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5350
Mailing Address - Country:US
Mailing Address - Phone:619-600-0683
Mailing Address - Fax:
Practice Address - Street 1:3575 KENYON ST STE 102
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-5350
Practice Address - Country:US
Practice Address - Phone:619-600-0683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-15-19856103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst