Provider Demographics
NPI:1316291800
Name:SHEA, GINA GAVAZZI (BCBA, LABA)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:GAVAZZI
Last Name:SHEA
Suffix:
Gender:F
Credentials:BCBA, LABA
Other - Prefix:MS
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:GAVAZZI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LABA
Mailing Address - Street 1:1 COMMERCIAL STREET
Mailing Address - Street 2:
Mailing Address - City:FOXBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02035
Mailing Address - Country:US
Mailing Address - Phone:508-772-1270
Mailing Address - Fax:
Practice Address - Street 1:1 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:FOXBORO
Practice Address - State:MA
Practice Address - Zip Code:02035-2530
Practice Address - Country:US
Practice Address - Phone:508-478-0207
Practice Address - Fax:508-634-6984
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
MA2039103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist