Provider Demographics
NPI:1518542026
Name:GEQUILLO, ALEXIS ANDIE (BCBA)
Entity type:Individual
Prefix:
First Name:ALEXIS ANDIE
Middle Name:
Last Name:GEQUILLO
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19750 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-1119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:996 ROYAL MARCO WAY
Practice Address - Street 2:
Practice Address - City:MARCO ISLAND
Practice Address - State:FL
Practice Address - Zip Code:34145-1829
Practice Address - Country:US
Practice Address - Phone:714-390-8965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-24-75448103K00000X
103K00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician