Provider Demographics
NPI:1821560947
Name:MACALUSO, AMYLYNN
Entity type:Individual
Prefix:
First Name:AMYLYNN
Middle Name:
Last Name:MACALUSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 EDGEWATER PL
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-1293
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 EDGEWATER PL
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-1293
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-31
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARBT-16-14711106S00000X
MA1-19-34819103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician