MEDICARE: ANTWANETTE DAILEY BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1013463041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTWANETTE DAILEY BCBA

Provider Business Mailing Address
First Line	:	PO BOX 399318
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94139-9318
Country	:	US
Telephone Number	:	866-523-4268
Fax Number	:

Provider Business Practice Location Address
First Line	:	2711 IRVIN WAY STE 201
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30030-1724
Country	:	US
Telephone Number	:	757-593-5662
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2016
Last Update Date	:	01/31/2023

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