Provider Demographics
NPI:1104227438
Name:CRIVELLO, RENEE (BCBA)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:CRIVELLO
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 1:26676 MORTON AVE
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-6308
Mailing Address - Country:US
Mailing Address - Phone:908-451-5480
Mailing Address - Fax:
Practice Address - Street 1:12871 TRADE WAY DR STE 1
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-7334
Practice Address - Country:US
Practice Address - Phone:786-259-0363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-05
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
1-21-47478103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017567400Medicaid