Provider Demographics
NPI:1548769607
Name:SPANGENBERG, BRIELLE AVA (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:BRIELLE
Middle Name:AVA
Last Name:SPANGENBERG
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 1:777 PARAMUS RD
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-1710
Mailing Address - Country:US
Mailing Address - Phone:201-612-7800
Mailing Address - Fax:201-670-1988
Practice Address - Street 1:777 PARAMUS RD
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-1710
Practice Address - Country:US
Practice Address - Phone:201-612-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-17-29056103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty