Provider Demographics
NPI:1821771882
Name:BACON, SAVANNAH R
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:R
Last Name:BACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 W MAPLE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:BOUND BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08805-1246
Mailing Address - Country:US
Mailing Address - Phone:609-218-9330
Mailing Address - Fax:
Practice Address - Street 1:2780 MORRIS AVE STE 1B
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-4848
Practice Address - Country:US
Practice Address - Phone:877-222-0399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst