1134746845 NPI number — MRS. GINA MARIE WEISS BCBA, LBA

Table of content: MRS. GINA MARIE WEISS BCBA, LBA (NPI 1134746845)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134746845 NPI number — MRS. GINA MARIE WEISS BCBA, LBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEISS
Provider First Name:
GINA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BCBA, LBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CORSO
Provider Other First Name:
GINA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
BCBA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134746845
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 ROXBURY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALLINGFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06492-6300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-917-8509
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 FARMINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06032-1728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-495-0126
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/29/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  48 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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