Provider Demographics
NPI:1770021321
Name:FARIAS, MADELINE (BCBA, LABA)
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:FARIAS
Suffix:
Gender:F
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 1:900 RIVERDALE ST UNIT 286
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-4900
Mailing Address - Country:US
Mailing Address - Phone:413-335-4492
Mailing Address - Fax:
Practice Address - Street 1:201 WOODCREST DR
Practice Address - Street 2:
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01020-2043
Practice Address - Country:US
Practice Address - Phone:413-335-4492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-03
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA3027-MH-B1103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid