Provider Demographics
NPI:1407424112
Name:WIECZOREK, ALENA GRACE (MS, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:ALENA
Middle Name:GRACE
Last Name:WIECZOREK
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:ALENA
Other - Middle Name:
Other - Last Name:WIECZOREK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RBT
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:5220 N DYSART RD BLDG C
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-3045
Practice Address - Country:US
Practice Address - Phone:623-244-9179
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBEH-001654103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-24-74461OtherBCBA CERTIFICATE