MEDICARE: ALEXIS AVELLAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-14-10203	NJ

General Provider Information

NPI Number	:	1144077801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXIS AVELLAN

Provider Business Mailing Address
First Line	:	294 E CLINTON AVE
Second Line	:
City	:	BERGENFIELD
State	:	NJ
Zip	:	07621-2528
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	294 E CLINTON AVE
Second Line	:
City	:	BERGENFIELD
State	:	NJ
Zip	:	07621-2528
Country	:	US
Telephone Number	:	201-259-4826
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2024
Last Update Date	:	05/01/2024

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Directions to “ ALEXIS AVELLAN ” Practice Location

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