Healthcare Provider Details

I. General information

NPI: 1942904016
Provider Name (Legal Business Name): COREY ALAN BERON BCABA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2023
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2314 MIAMI ST
SOUTH BEND IN
46614-1336
US

IV. Provider business mailing address

2314 MIAMI ST
SOUTH BEND IN
46614-1336
US

V. Phone/Fax

Practice location:
  • Phone: 574-329-6856
  • Fax: 574-367-2922
Mailing address:
  • Phone: 574-329-6856
  • Fax: 574-367-2922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-20-11409
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: