Provider Demographics
NPI:1730651357
Name:MOONEN, JOLISA (BCBA)
Entity Type:Individual
Prefix:
First Name:JOLISA
Middle Name:
Last Name:MOONEN
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 1:1955 W GRANT RD STE 180
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-1475
Mailing Address - Country:US
Mailing Address - Phone:844-333-6642
Mailing Address - Fax:520-333-3060
Practice Address - Street 1:1955 W GRANT RD STE 180
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-1475
Practice Address - Country:US
Practice Address - Phone:844-333-6642
Practice Address - Fax:520-333-3060
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBEH-000412103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBEH-000412OtherSTATE LICENSE