Basic Information
| Provider Information | |||||||||
| NPI: | 1386106185 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GENAO | ||||||||
| FirstName: | VLADIMIR | ||||||||
| MiddleName: | JUNIOR | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, BCBA, LABA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 ROBINSON ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | LYNN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019051813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819138512 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 607 NORTH AVE | ||||||||
| Address2: | DOOR 11 | ||||||||
| City: | WAKEFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669264345 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2019 | ||||||||
| LastUpdateDate: | 01/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | 2629 | MA | N | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 2629 | 01 | MA | LABA | OTHER |