Provider Demographics
NPI:1952718033
Name:HOLDERBACH, MELISSA J (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:J
Last Name:HOLDERBACH
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:691 HILLS ST
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06118-3036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:691 HILLS ST
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06118-3036
Practice Address - Country:US
Practice Address - Phone:860-966-1361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1-11-8249103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst