Provider Demographics
NPI:1467837559
Name:FLYNN, MARY (BCBA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FLYNN
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 1:2700 CROTON RD
Mailing Address - Street 2:2-48
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935
Mailing Address - Country:US
Mailing Address - Phone:321-576-5062
Mailing Address - Fax:
Practice Address - Street 1:2700 CROTON RD
Practice Address - Street 2:2-48
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935
Practice Address - Country:US
Practice Address - Phone:321-576-5062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-04-1927103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst