Provider Demographics
NPI:1194241059
Name:GERAGHTY, MARISSA (BCBA)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:GERAGHTY
Suffix:
Gender:
Credentials:BCBA
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:PERRI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1509 E COLONIAL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-4729
Mailing Address - Country:US
Mailing Address - Phone:407-317-5429
Mailing Address - Fax:321-800-7201
Practice Address - Street 1:758 N SUN DR STE 112
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2599
Practice Address - Country:US
Practice Address - Phone:407-317-5429
Practice Address - Fax:321-800-7201
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
FL1-22-62247103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022049000Medicaid