Provider Demographics
NPI:1356937056
Name:WALDRON, REILLY L (BCBA, LABA)
Entity type:Individual
Prefix:
First Name:REILLY
Middle Name:L
Last Name:WALDRON
Suffix:
Gender:M
Credentials:BCBA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01803-2203
Mailing Address - Country:US
Mailing Address - Phone:781-724-2670
Mailing Address - Fax:
Practice Address - Street 1:515 GROTON RD
Practice Address - Street 2:
Practice Address - City:WESTFORD
Practice Address - State:MA
Practice Address - Zip Code:01886-6321
Practice Address - Country:US
Practice Address - Phone:800-679-3609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALABA10001150103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst