Provider Demographics
NPI:1528648896
Name:WISOTSKY, RACHELLE (BCBA)
Entity type:Individual
Prefix:
First Name:RACHELLE
Middle Name:
Last Name:WISOTSKY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 RANDOLPH AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06710-1624
Mailing Address - Country:US
Mailing Address - Phone:845-608-9766
Mailing Address - Fax:
Practice Address - Street 1:115 RANDOLPH AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06710-1624
Practice Address - Country:US
Practice Address - Phone:845-608-9766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst