Provider Demographics
NPI:1487185609
Name:MASTROGIACOMO, LORI E (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:E
Last Name:MASTROGIACOMO
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:972 POST RD
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:DARIEN
Mailing Address - State:CT
Mailing Address - Zip Code:06820-4525
Mailing Address - Country:US
Mailing Address - Phone:203-883-8827
Mailing Address - Fax:
Practice Address - Street 1:972 POST RD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:DARIEN
Practice Address - State:CT
Practice Address - Zip Code:06820-4525
Practice Address - Country:US
Practice Address - Phone:203-883-8827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1-00-0007103K00000X
NY000323103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst