Provider Demographics
NPI:1588325211
Name:FASANO, LAURA (BCBA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:FASANO
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 1:59 DANBURY RD
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-4405
Mailing Address - Country:US
Mailing Address - Phone:203-210-7124
Mailing Address - Fax:
Practice Address - Street 1:1700 REISTERSTOWN RD STE 220
Practice Address - Street 2:
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-2920
Practice Address - Country:US
Practice Address - Phone:443-213-5906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1-21-55493103K00000X
CT1351103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst