Provider Demographics
NPI:1700308731
Name:PONTICELLI, TAMARLA RAELYNN (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:TAMARLA
Middle Name:RAELYNN
Last Name:PONTICELLI
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3351 CARROLL CT
Mailing Address - Street 2:
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-1817
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 WELSH RD STE 100
Practice Address - Street 2:
Practice Address - City:HORSHAM
Practice Address - State:PA
Practice Address - Zip Code:19044-2248
Practice Address - Country:US
Practice Address - Phone:267-209-3410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-12
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156F00000X
11935456103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No156F00000XEye and Vision Services ProvidersTechnician/Technologist