Provider Demographics
NPI:1134796782
Name:CARLSON, STEPHANIE ANN (BCBA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:CARLSON
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 1:29 HOPE STREET
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:CAMBRIDGESHIRE
Mailing Address - Zip Code:CB1 3NA
Mailing Address - Country:GB
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29 HOPE STREET
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:CAMBRIDGESHIRE
Practice Address - Zip Code:CB1 3NA
Practice Address - Country:GB
Practice Address - Phone:707-631-3071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
BACB538103103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst