Provider Demographics
NPI:1336509769
Name:FENNESSY, MEGHAN PATRICE (MED, LABA, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:MEGHAN
Middle Name:PATRICE
Last Name:FENNESSY
Suffix:
Gender:F
Credentials:MED, LABA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02189-2317
Mailing Address - Country:US
Mailing Address - Phone:617-861-1763
Mailing Address - Fax:
Practice Address - Street 1:1290 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02189-2317
Practice Address - Country:US
Practice Address - Phone:617-861-1763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA437103K00000X
MA1084005103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst