Provider Demographics
NPI:1982137196
Name:KERVICK, TARA (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:
Last Name:KERVICK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 CHELMSFORD ST
Mailing Address - Street 2:
Mailing Address - City:CHELMSFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01824-2305
Mailing Address - Country:US
Mailing Address - Phone:978-732-7171
Mailing Address - Fax:
Practice Address - Street 1:205 BURLINGTON RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:01730-1406
Practice Address - Country:US
Practice Address - Phone:781-862-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106S00000X
MA3467-MH-B1103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA042611055OtherTAX ID
MA1004745OtherNHP
MA1303287OtherMBHP
MAM18633OtherBCBS
MA1004745OtherFALLON
MA0000023532OtherBMC
MA99618201OtherNETWORK HEALTH