Provider Demographics
NPI:1750762399
Name:PASSAGE, MICHAEL JONATHAN (BCBA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JONATHAN
Last Name:PASSAGE
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 W UPSAL ST
Mailing Address - Street 2:A202
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-3264
Mailing Address - Country:US
Mailing Address - Phone:862-202-1516
Mailing Address - Fax:
Practice Address - Street 1:246 W UPSAL ST
Practice Address - Street 2:A202
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-3264
Practice Address - Country:US
Practice Address - Phone:862-202-1516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH002606103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-14-16814OtherBCBA