Individual
GLORIA LEYLA FANNING TACOAMAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
60 CONCORD ST STE 1, WILMINGTON, MA 01887-2179
(781) 694-8787
Mailing address
41 PACELLA PARK DR, RANDOLPH, MA 02368-1755
(781) 437-0791
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
—
103K00000X
Behavior Analyst
Primary
LABA10000079
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
110026265E
—
MA
Enumeration date
08/04/2020
Last updated
05/09/2023
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