Basic Information
| Provider Information | |||||||||
| NPI: | 1588295844 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BELLONE | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CCC-SLP, BCBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BELLONE | ||||||||
| OtherFirstName: | BETH | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CCC-SLP, BCBA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 33 TURNPIKE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHBOROUGH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017722108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084811015 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 33 TURNPIKE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHBOROUGH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017722108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084811015 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2020 | ||||||||
| LastUpdateDate: | 01/27/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 328 | MA | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 235Z00000X | 3782 | MA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.