Provider Demographics
NPI:1063150134
Name:MOONEY, MICHELE A (BCBA)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:A
Last Name:MOONEY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HARVARD DR
Mailing Address - Street 2:
Mailing Address - City:WALDEN
Mailing Address - State:NY
Mailing Address - Zip Code:12586-1615
Mailing Address - Country:US
Mailing Address - Phone:571-358-2087
Mailing Address - Fax:
Practice Address - Street 1:107 W 82ND ST STE P101
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-5511
Practice Address - Country:US
Practice Address - Phone:646-389-4112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001853-01103K00000X
1-17-27773103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst