Provider Demographics
NPI:1487429023
Name:WORMWOOD, ALANNA ROSE (BCBA)
Entity type:Individual
Prefix:
First Name:ALANNA
Middle Name:ROSE
Last Name:WORMWOOD
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 1:5390 HEMLOCK DR APT 1002B
Mailing Address - Street 2:
Mailing Address - City:LOWVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13367-1871
Mailing Address - Country:US
Mailing Address - Phone:315-804-7092
Mailing Address - Fax:
Practice Address - Street 1:5390 HEMLOCK DR APT 1002B
Practice Address - Street 2:
Practice Address - City:LOWVILLE
Practice Address - State:NY
Practice Address - Zip Code:13367-1871
Practice Address - Country:US
Practice Address - Phone:315-804-7092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1-23-68044103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst