Provider Demographics
NPI:1649533167
Name:PIACENTINI, CARLY (MS, BCBA)
Entity type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:
Last Name:PIACENTINI
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:MS
Other - First Name:CARLY
Other - Middle Name:
Other - Last Name:CORNELIUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, BCBA
Mailing Address - Street 1:9616 PORTAGE RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-7257
Mailing Address - Country:US
Mailing Address - Phone:269-929-3850
Mailing Address - Fax:
Practice Address - Street 1:9616 PORTAGE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-7257
Practice Address - Country:US
Practice Address - Phone:269-929-3850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-12-10212103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst