Provider Demographics
NPI:1235604885
Name:BLANCOVICH, BRIANNA (BCBA)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:BLANCOVICH
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 1:122 BUSINESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-6321
Mailing Address - Country:US
Mailing Address - Phone:315-732-3431
Mailing Address - Fax:866-822-2343
Practice Address - Street 1:122 BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-6321
Practice Address - Country:US
Practice Address - Phone:315-732-3431
Practice Address - Fax:866-822-2343
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP09991103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst