Provider Demographics
NPI:1851540041
Name:STOVELL, THERESA M (MS ED, BCBA)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:M
Last Name:STOVELL
Suffix:
Gender:F
Credentials:MS ED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 MANOR RD UNIT 140966
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-2970
Mailing Address - Country:US
Mailing Address - Phone:917-921-3912
Mailing Address - Fax:718-273-0013
Practice Address - Street 1:66 ELIZABETH AVE APT 2
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-1510
Practice Address - Country:US
Practice Address - Phone:917-921-3912
Practice Address - Fax:718-273-0013
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-12
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 174400000X
1-21-57318103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialist