Provider Demographics
NPI:1568735843
Name:FAVREAU, BLUE WILLOW (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:BLUE
Middle Name:WILLOW
Last Name:FAVREAU
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 1:109 CHACE HILL RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:MA
Mailing Address - Zip Code:01564-1519
Mailing Address - Country:US
Mailing Address - Phone:978-365-3891
Mailing Address - Fax:
Practice Address - Street 1:109 CHACE HILL RD
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:MA
Practice Address - Zip Code:01564-1519
Practice Address - Country:US
Practice Address - Phone:978-365-3891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-04-1792103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst