Provider Demographics
NPI:1104120906
Name:HERSCOVITCH, BRANDON (PHD, BCBA-D)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:
Last Name:HERSCOVITCH
Suffix:
Gender:M
Credentials:PHD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 SHATTUCK RD UNIT 2402
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-2475
Mailing Address - Country:US
Mailing Address - Phone:978-806-1455
Mailing Address - Fax:
Practice Address - Street 1:715 S HALLIBURTON ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4156
Practice Address - Country:US
Practice Address - Phone:978-806-1455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-07
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022036699103K00000X
MA51103K00000X
1-06-3079103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst