Provider Demographics
NPI:1174250419
Name:DORSEY, ELYSSA PETTEPIT (BCBA, LABA)
Entity type:Individual
Prefix:
First Name:ELYSSA
Middle Name:PETTEPIT
Last Name:DORSEY
Suffix:
Gender:F
Credentials:BCBA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 WATERCOURSE PL
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-3626
Mailing Address - Country:US
Mailing Address - Phone:508-254-0692
Mailing Address - Fax:
Practice Address - Street 1:116 HELEN DR
Practice Address - Street 2:
Practice Address - City:HANSON
Practice Address - State:MA
Practice Address - Zip Code:02341-1207
Practice Address - Country:US
Practice Address - Phone:781-924-1408
Practice Address - Fax:781-924-3293
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA179103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst