=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003380056
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA PANEBIANCO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2019
-----------------------------------------------------
Last Update Date | 01/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2631 MERRICK RD STE 302
-----------------------------------------------------
City | BELLMORE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11710-5784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-569-9847
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 266 MOTT ST
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11572-5518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-673-1184
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------