Provider Demographics
NPI:1548810765
Name:BASSANO, TIA (EDS, BCBA, NCSP)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:BASSANO
Suffix:
Gender:F
Credentials:EDS, BCBA, NCSP
Other - Prefix:
Other - First Name:TIA
Other - Middle Name:BASSANO
Other - Last Name:CICHON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:EDS, BCBA, NCSP
Mailing Address - Street 1:3279 NOTTINGHAM WAY
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-1860
Mailing Address - Country:US
Mailing Address - Phone:609-602-8004
Mailing Address - Fax:
Practice Address - Street 1:1000 CRAWFORD PL STE 260
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-3965
Practice Address - Country:US
Practice Address - Phone:856-628-1686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-14-16629103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst