Provider Demographics
NPI:1215247382
Name:WALL, CYNTHIA IRENE (BCBA)
Entity type:Individual
Prefix:MISS
First Name:CYNTHIA
Middle Name:IRENE
Last Name:WALL
Suffix:
Gender:F
Credentials:BCBA
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Mailing Address - Street 1:19019 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3253
Mailing Address - Country:US
Mailing Address - Phone:818-345-2345
Mailing Address - Fax:818-758-8015
Practice Address - Street 1:118 LONG POND RD
Practice Address - Street 2:SUITE 205
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2662
Practice Address - Country:US
Practice Address - Phone:508-732-0088
Practice Address - Fax:508-732-0078
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA1-11-8622103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst