Provider Demographics
NPI:1497039010
Name:MAZZOTTI, MICHELLE FROST (BCBA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:FROST
Last Name:MAZZOTTI
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 1:780 AMERICAN LEGION HWY
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-3908
Mailing Address - Country:US
Mailing Address - Phone:732-742-6256
Mailing Address - Fax:
Practice Address - Street 1:1420 CAMPBELL ST APT 215
Practice Address - Street 2:
Practice Address - City:RAHWAY
Practice Address - State:NJ
Practice Address - Zip Code:07065-3291
Practice Address - Country:US
Practice Address - Phone:732-742-6256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-30
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
1-16-23775103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program