Provider Demographics
NPI:1396285318
Name:GANGULI, MARY JENESS (BCBA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JENESS
Last Name:GANGULI
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JENESS
Other - Last Name:KEDDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:338 VIA VERA CRUZ STE 130
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-2645
Mailing Address - Country:US
Mailing Address - Phone:866-727-8274
Mailing Address - Fax:
Practice Address - Street 1:338 VIA VERA CRUZ STE 130
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-2645
Practice Address - Country:US
Practice Address - Phone:866-727-8274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-24
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst