Healthcare Provider Details

I. General information

NPI: 1568825917
Provider Name (Legal Business Name): HEATHER LYNN EVANGELISTI BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEATHER LYNN BULLOCK BCBA

II. Dates (important events)

Enumeration Date: 04/03/2016
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 FALL MOUNTAIN RD
BRISTOL CT
06010-5983
US

IV. Provider business mailing address

282 FALL MOUNTAIN RD
BRISTOL CT
06010-5983
US

V. Phone/Fax

Practice location:
  • Phone: 203-768-7802
  • Fax:
Mailing address:
  • Phone: 203-768-7802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number187
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: