Healthcare Provider Details

I. General information

NPI: 1285215228
Provider Name (Legal Business Name): CRISTINA DIBACCO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 WHITING ST
NEW BRITAIN CT
06051-3184
US

IV. Provider business mailing address

144 MAIN ST STE G
EAST HARTFORD CT
06118-3239
US

V. Phone/Fax

Practice location:
  • Phone: 888-754-0398
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1328
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: