Provider Demographics
NPI:1457823916
Name:BAEZ, EVANGELINA (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:EVANGELINA
Middle Name:
Last Name:BAEZ
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 MISTY HILLS LN
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-6156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:162 WEST ST STE F
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:CT
Practice Address - Zip Code:06416-4405
Practice Address - Country:US
Practice Address - Phone:860-613-9930
Practice Address - Fax:860-613-9952
Is Sole Proprietor?:No
Enumeration Date:2018-12-21
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1-18-31941103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst