Provider Demographics
NPI:1942944095
Name:DEBARTOLO, ERICA GWEN (BA)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:GWEN
Last Name:DEBARTOLO
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 OSCARS WAY
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-4721
Mailing Address - Country:US
Mailing Address - Phone:781-492-5710
Mailing Address - Fax:
Practice Address - Street 1:384 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORWELL
Practice Address - State:MA
Practice Address - Zip Code:02061-2010
Practice Address - Country:US
Practice Address - Phone:781-871-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106E00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst