Healthcare Provider Details

I. General information

NPI: 1881345825
Provider Name (Legal Business Name): MICAELA BANEY FULLMAN BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 PORTLAND RD
ARUNDEL ME
04046-7950
US

IV. Provider business mailing address

148 DOUGHTY BLVD
INWOOD NY
11096-2047
US

V. Phone/Fax

Practice location:
  • Phone: 207-292-5891
  • Fax:
Mailing address:
  • Phone: 404-400-5004
  • Fax: 203-547-6280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number3760
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: