Provider Demographics
NPI:1962842930
Name:WACHSMUTH, TATIANA (BCBA)
Entity Type:Individual
Prefix:MS
First Name:TATIANA
Middle Name:
Last Name:WACHSMUTH
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 PINEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06903-2522
Mailing Address - Country:US
Mailing Address - Phone:860-248-5372
Mailing Address - Fax:
Practice Address - Street 1:19 PINEWOOD RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06903-2522
Practice Address - Country:US
Practice Address - Phone:860-248-5372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-04
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-13-13547103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst