=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245770429
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALLISON MAYERNICK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2017
-----------------------------------------------------
Last Update Date | 08/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 317 HOLLIE DR E
-----------------------------------------------------
City | BELFORD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07718-1264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 185-583-2672
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 424 WHITON ST APT 402
-----------------------------------------------------
City | JERSEY CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07304-4148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-436-3423
-----------------------------------------------------
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 | 1-19-34901
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-19-34901
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------