Provider Demographics
NPI:1245731462
Name:AVAGYAN, MARINE (BCBA)
Entity type:Individual
Prefix:
First Name:MARINE
Middle Name:
Last Name:AVAGYAN
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 1:150 GLEN COVE MARINA RD E STE 102
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-7237
Mailing Address - Country:US
Mailing Address - Phone:707-553-1784
Mailing Address - Fax:
Practice Address - Street 1:150 GLEN COVE MARINA RD E STE 102
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591-7237
Practice Address - Country:US
Practice Address - Phone:707-553-1784
Practice Address - Fax:510-373-1738
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16-15400106S00000X
CA1-24-71351103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician