Healthcare Provider Details

I. General information

NPI: 1194242982
Provider Name (Legal Business Name): ELIZA CAGLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 BALTIMORE ANNAPOLIS BLVD STE 216-217
SEVERNA PARK MD
21146-3931
US

IV. Provider business mailing address

1 VERNEY DR
GREENFIELD NH
03047-5000
US

V. Phone/Fax

Practice location:
  • Phone: 800-676-5130
  • Fax: 888-958-5753
Mailing address:
  • Phone: 603-831-3091
  • Fax: 603-410-1105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-38417
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-17-35873
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: