Provider Demographics
NPI:1548627441
Name:FEDOROCSKO, ELENA ALEXIS (BCBA)
Entity type:Individual
Prefix:MISS
First Name:ELENA
Middle Name:ALEXIS
Last Name:FEDOROCSKO
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 1:7901 HENRY AVE APT F301
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-3008
Mailing Address - Country:US
Mailing Address - Phone:267-377-6868
Mailing Address - Fax:
Practice Address - Street 1:3744 W CHESTER PIKE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NEWTOWN SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073-3224
Practice Address - Country:US
Practice Address - Phone:610-864-7376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBACB265951103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst