Healthcare Provider Details

I. General information

NPI: 1497026942
Provider Name (Legal Business Name): PETAGAYE SIMONE TOWNSEND MS, BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2012
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8480 BALTIMORE NATIONAL PIKE STE 3210 #126
ELLICOTT CITY MD
21043
US

IV. Provider business mailing address

8480 BALTIMORE NATIONAL PIKE STE 3210 #126
ELLICOTT CITY MD
21043-1420
US

V. Phone/Fax

Practice location:
  • Phone: 914-363-8313
  • Fax:
Mailing address:
  • Phone: 914-363-8313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-14-9454
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number1125719
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: