Provider Demographics
NPI:1912413477
Name:DOMZALSKI, MEGAN ELIZABETH (MA, BCBA)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:ELIZABETH
Last Name:DOMZALSKI
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WARREN ST
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-6406
Mailing Address - Country:US
Mailing Address - Phone:908-268-9279
Mailing Address - Fax:
Practice Address - Street 1:5 RAVEN LN
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-4968
Practice Address - Country:US
Practice Address - Phone:732-730-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-17-27664103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst