Provider Demographics
NPI:1093217168
Name:GARANOVSKIY, MARY (BCBA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GARANOVSKIY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:MASHA
Other - Middle Name:
Other - Last Name:GARANOVSKAYA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9423 SE SPYGLASS DR
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-7313
Mailing Address - Country:US
Mailing Address - Phone:503-730-3225
Mailing Address - Fax:
Practice Address - Street 1:9423 SE SPYGLASS DR
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-7313
Practice Address - Country:US
Practice Address - Phone:503-730-3225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-05
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORB-10217191103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95700652GOtherMEDI-CAL