Provider Demographics
NPI:1831663079
Name:MICUNOVIC, TATJANA
Entity type:Individual
Prefix:
First Name:TATJANA
Middle Name:
Last Name:MICUNOVIC
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 1:30 MILL ST UNIT 211
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-4767
Mailing Address - Country:US
Mailing Address - Phone:508-369-8049
Mailing Address - Fax:
Practice Address - Street 1:30 MILL ST UNIT 211
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-4767
Practice Address - Country:US
Practice Address - Phone:508-369-8049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2025-10-27
Deactivation Date:2019-03-07
Deactivation Code:
Reactivation Date:2019-04-17
Provider Licenses
StateLicense IDTaxonomies
MALABA10001780103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty