Provider Demographics
NPI:1558740399
Name:PUISSEAUX BASSAVE, JANNETTE DE LA CARIDAD (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:JANNETTE
Middle Name:DE LA CARIDAD
Last Name:PUISSEAUX BASSAVE
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 1:119 S WOLFE ST
Mailing Address - Street 2:APT 4
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-1960
Mailing Address - Country:US
Mailing Address - Phone:301-910-1299
Mailing Address - Fax:
Practice Address - Street 1:119 S WOLFE ST
Practice Address - Street 2:APT 4
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-1960
Practice Address - Country:US
Practice Address - Phone:301-910-1299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1-15-17987103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst