Provider Demographics
NPI:1578193488
Name:WHITEBREAD, CHRISTIAN (BCBA)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:WHITEBREAD
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4055 RIDGE AVE APT 7306
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1594
Mailing Address - Country:US
Mailing Address - Phone:570-956-9470
Mailing Address - Fax:
Practice Address - Street 1:413 FAIRMOUNT AVE STE 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-2872
Practice Address - Country:US
Practice Address - Phone:267-908-7772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1-18-30608103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst