Provider Demographics
NPI:1710188909
Name:VAN HOLLENBECK, MARY-THERESE C (MA,BCBA)
Entity Type:Individual
Prefix:MS
First Name:MARY-THERESE
Middle Name:C
Last Name:VAN HOLLENBECK
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 1:576 CYPRESS RD
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-1723
Mailing Address - Country:US
Mailing Address - Phone:772-473-9830
Mailing Address - Fax:
Practice Address - Street 1:576 CYPRESS RD
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32963-1723
Practice Address - Country:US
Practice Address - Phone:772-473-9830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst