Provider Demographics
NPI:1285379719
Name:FANELLI, CHARLES WILLIS (BCBA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILLIS
Last Name:FANELLI
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5272 RIVER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20816-1454
Mailing Address - Country:US
Mailing Address - Phone:301-718-1716
Mailing Address - Fax:
Practice Address - Street 1:5272 RIVER RD STE 100
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20816-1454
Practice Address - Country:US
Practice Address - Phone:301-718-1716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLBA1279103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst