=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124775069
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIELLE CELLUCCI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2022
-----------------------------------------------------
Last Update Date | 07/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 113 SALEM TPKE STE 200
-----------------------------------------------------
City | NORWICH
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06360-6484
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-207-7907
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 NEW SWEDEN RD
-----------------------------------------------------
City | WOODSTOCK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06281-3213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-207-7907
-----------------------------------------------------
Fax | 800-819-7806
-----------------------------------------------------
=====================================================
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 | 1404
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------