Provider Demographics
NPI:1942904016
Name:BERON, COREY ALAN (BCABA)
Entity Type:Individual
Prefix:MR
First Name:COREY
Middle Name:ALAN
Last Name:BERON
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2314 MIAMI ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-1336
Mailing Address - Country:US
Mailing Address - Phone:574-329-6856
Mailing Address - Fax:574-367-2922
Practice Address - Street 1:2314 MIAMI ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-1336
Practice Address - Country:US
Practice Address - Phone:574-329-6856
Practice Address - Fax:574-367-2922
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0-20-11409106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty