Provider Demographics
NPI:1821455692
Name:GIDULA, CORISSA (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:CORISSA
Middle Name:
Last Name:GIDULA
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 1:848 BUCCANEER LN
Mailing Address - Street 2:
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-2112
Mailing Address - Country:US
Mailing Address - Phone:484-258-6050
Mailing Address - Fax:
Practice Address - Street 1:848 BUCCANEER LN
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2112
Practice Address - Country:US
Practice Address - Phone:484-258-6050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-22-59762103K00000X
GAAPC004512101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst