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General NPI Number Information
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NPI Number | 1679829162
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Entity Type | Organization
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Legal Business Name | STONEBRIDGE BEHAVIORAL SERVICES
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Dates
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Enumeration Date | 08/02/2012
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Last Update Date | 08/22/2016
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Provider Practice Location Address
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Address Line | 16 BRIDGE GATE
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City | PLYMOUTH
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State | MA
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Zip | 02360-6377
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Country | US
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Telephone | 508-287-8692
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Fax | 508-591-7886
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Provider Business Mailing Address
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Address Line | 16 BRIDGE GATE
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City | PLYMOUTH
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State | MA
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Zip | 02360-6377
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Country | US
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Telephone | 508-287-8692
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Fax | 508-591-7886
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | DR. GORDON ANTHONY DEFALCO
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Credential | PHD, BCBA-D, LABA
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Telephone | 508-287-8692
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1-04-1493
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License Number State |
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