Provider Demographics
NPI:1679829162
Name:STONEBRIDGE BEHAVIORAL SERVICES
Entity Type:Organization
Organization Name:STONEBRIDGE BEHAVIORAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DEFALCO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, BCBA-D, LABA
Authorized Official - Phone:508-287-8692
Mailing Address - Street 1:16 BRIDGE GATE
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-6377
Mailing Address - Country:US
Mailing Address - Phone:508-287-8692
Mailing Address - Fax:508-591-7886
Practice Address - Street 1:16 BRIDGE GATE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-6377
Practice Address - Country:US
Practice Address - Phone:508-287-8692
Practice Address - Fax:508-591-7886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-02
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-04-1493103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty