Provider Demographics
NPI:1093470742
Name:DORSO, JAYRA (M ED BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:JAYRA
Middle Name:
Last Name:DORSO
Suffix:
Gender:F
Credentials:M ED BCBA, LBA
Other - Prefix:
Other - First Name:JAYRA
Other - Middle Name:
Other - Last Name:DORSO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED, BCBA, LBA
Mailing Address - Street 1:12 SPINDLE HILL RD APT 7G
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716-1743
Mailing Address - Country:US
Mailing Address - Phone:203-565-9037
Mailing Address - Fax:
Practice Address - Street 1:12 SPINDLE HILL RD APT 7G
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-1743
Practice Address - Country:US
Practice Address - Phone:203-565-9037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-07
Last Update Date:2021-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1318103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst