Provider Demographics
NPI:1134746845
Name:WEISS, GINA MARIE (BCBA, LBA)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARIE
Last Name:WEISS
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:MISS
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:CORSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:10 ROXBURY LN
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-6300
Mailing Address - Country:US
Mailing Address - Phone:860-917-8509
Mailing Address - Fax:
Practice Address - Street 1:160 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1728
Practice Address - Country:US
Practice Address - Phone:860-495-0126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT48103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst