Healthcare Provider Details

I. General information

NPI: 1134598519
Provider Name (Legal Business Name): CORY MITCHELL BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 HMS STAYNER DR
HINGHAM MA
02043-1664
US

IV. Provider business mailing address

105 HMS STAYNER DR
HINGHAM MA
02043-1664
US

V. Phone/Fax

Practice location:
  • Phone: 617-957-6451
  • Fax: 781-385-7324
Mailing address:
  • Phone: 978-953-9200
  • Fax: 800-928-1315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number3649
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: