Provider Demographics
NPI:1215702477
Name:DISTASI, VERONICA (MA, BCBA)
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:
Last Name:DISTASI
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 AUTUMN LN APT 208A
Mailing Address - Street 2:
Mailing Address - City:GARFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07026-4603
Mailing Address - Country:US
Mailing Address - Phone:973-508-5644
Mailing Address - Fax:
Practice Address - Street 1:329 AYCRIGG AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-3713
Practice Address - Country:US
Practice Address - Phone:973-471-3046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-21-52324103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst