Provider Demographics
NPI:1568825917
Name:EVANGELISTI, HEATHER (BCBA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:EVANGELISTI
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:BULLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:282 FALL MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-5983
Mailing Address - Country:US
Mailing Address - Phone:203-768-7802
Mailing Address - Fax:
Practice Address - Street 1:19 S GEORGE WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4541
Practice Address - Country:US
Practice Address - Phone:860-462-7322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-03
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT187103K00000X
CT11416507103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst