Healthcare Provider Details

I. General information

NPI: 1982137196
Provider Name (Legal Business Name): TARA KERVICK BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 BURLINGTON RD
BEDFORD MA
01730-1406
US

IV. Provider business mailing address

227 CHELMSFORD ST
CHELMSFORD MA
01824-2305
US

V. Phone/Fax

Practice location:
  • Phone: 781-862-3600
  • Fax:
Mailing address:
  • Phone: 978-732-7171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number3467-MH-B1
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: