Basic Information
| Provider Information | |||||||||
| NPI: | 1831461151 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DITULLIO | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS., BCBA, LABA. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DITULLIO | ||||||||
| OtherFirstName: | BRANDON | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 205 BURLINGTON RD | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017301406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818623600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 345 GREENWOOD ST STE A | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016071767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083630200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2012 | ||||||||
| LastUpdateDate: | 01/07/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 2516 | MA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1303287 | 01 | MA | MBHP | OTHER | 1004745 | 01 | MA | NHP | OTHER | M18633 | 01 | MA | BCBS | OTHER | 0000023532 | 01 | MA | BMC | OTHER | 1303287 | 05 | MA | MEDICAID | 042611055 | 01 | MA | TAX ID | OTHER | 99618201 | 01 | MA | NETWORK HEALTH | OTHER |