Healthcare Provider Details

I. General information

NPI: 1538730742
Provider Name (Legal Business Name): CAROLYN WITROCK BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2021
Last Update Date: 04/04/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1991 NORTHHAMPTON STREET
EASTON PA
18042-3173
US

IV. Provider business mailing address

1991 NORTHHAMPTON STREET
EASTON PA
18042-3173
US

V. Phone/Fax

Practice location:
  • Phone: 888-726-4774
  • Fax:
Mailing address:
  • Phone: 888-726-4774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBH006321
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-131552
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: