Provider Demographics
NPI:1003264565
Name:DETIG, ALYSON TERESE (BCBA)
Entity Type:Individual
Prefix:MS
First Name:ALYSON
Middle Name:TERESE
Last Name:DETIG
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 1:35 WALTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW PROVIDENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:07974-1745
Mailing Address - Country:US
Mailing Address - Phone:908-723-6380
Mailing Address - Fax:
Practice Address - Street 1:1071 VALLEY RD
Practice Address - Street 2:
Practice Address - City:STIRLING
Practice Address - State:NJ
Practice Address - Zip Code:07980-1523
Practice Address - Country:US
Practice Address - Phone:906-604-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ11521250103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst