Provider Demographics
NPI:1265905996
Name:PANDULLO, DEBORAH (BCBA)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:PANDULLO
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 1:2158 CASA GRANDE ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-4105
Mailing Address - Country:US
Mailing Address - Phone:626-372-9474
Mailing Address - Fax:
Practice Address - Street 1:275 W HOSPITALITY LN # 324
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3249
Practice Address - Country:US
Practice Address - Phone:800-951-9813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-14-15745103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst