Provider Demographics
NPI:1174238232
Name:NEAL, TANNIS OLIVIA (BCBA, LBA)
Entity type:Individual
Prefix:
First Name:TANNIS
Middle Name:OLIVIA
Last Name:NEAL
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 HIGHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06514-2819
Mailing Address - Country:US
Mailing Address - Phone:203-361-4844
Mailing Address - Fax:
Practice Address - Street 1:1 ENTERPRISE DR STE 110
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-4631
Practice Address - Country:US
Practice Address - Phone:203-900-4720
Practice Address - Fax:203-306-3219
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-23
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1582103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst