Provider Demographics
NPI:1306230156
Name:ELLIOTT O'LEARY LEWACK, VANESSA S (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:S
Last Name:ELLIOTT O'LEARY LEWACK
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 1:21 CHAMBERLAIN RUN
Mailing Address - Street 2:
Mailing Address - City:HINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02043-1921
Mailing Address - Country:US
Mailing Address - Phone:617-827-9136
Mailing Address - Fax:
Practice Address - Street 1:749 E INDUSTRIAL PARK DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03109-5618
Practice Address - Country:US
Practice Address - Phone:866-352-5010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-18
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA349357103K00000X
MALABA3414103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst