Provider Demographics
NPI:1265998827
Name:MURDOCK, LAURETTA ELAINE (BCBA, LBA)
Entity type:Individual
Prefix:
First Name:LAURETTA
Middle Name:ELAINE
Last Name:MURDOCK
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:LORETTA
Other - Middle Name:ELAINE
Other - Last Name:MURDOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BCBA, LBA
Mailing Address - Street 1:C/O THE MOSAIC FOUNDATION FOR AUTISM, INC.
Mailing Address - Street 2:1725 BRENTWOOD RD.
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717
Mailing Address - Country:US
Mailing Address - Phone:631-617-6333
Mailing Address - Fax:631-617-6334
Practice Address - Street 1:C/O THE MOSAIC FOUNDATION FOR AUTISM, INC.
Practice Address - Street 2:1725 BRENTWOOD RD.
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717
Practice Address - Country:US
Practice Address - Phone:631-617-6333
Practice Address - Fax:631-617-6334
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYLBA0600103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst