Provider Demographics
NPI:1285713685
Name:DEFALCO, GORDON ANTHONY (BCBA-D,PHD,LABA)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:ANTHONY
Last Name:DEFALCO
Suffix:
Gender:M
Credentials:BCBA-D,PHD,LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BRIDGE GATE
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-6377
Mailing Address - Country:US
Mailing Address - Phone:508-287-8692
Mailing Address - Fax:508-591-7886
Practice Address - Street 1:16 BRIDGE GATE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-6377
Practice Address - Country:US
Practice Address - Phone:508-287-8692
Practice Address - Fax:508-591-7886
Is Sole Proprietor?:No
Enumeration Date:2006-11-04
Last Update Date:2016-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-04-1493103TB0200X
MA882103K00000X
MA1-04-1493103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral