Provider Demographics
NPI:1396283305
Name:DAVINI, JODY L (REGISTIR BEHAVIOR T)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:L
Last Name:DAVINI
Suffix:
Gender:F
Credentials:REGISTIR BEHAVIOR T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 PILGRIM AVE
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-4714
Mailing Address - Country:US
Mailing Address - Phone:508-371-0384
Mailing Address - Fax:
Practice Address - Street 1:125 PILGRIM AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-4714
Practice Address - Country:US
Practice Address - Phone:508-371-0384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1612698106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician