MEDICARE: SHANE KNOLL

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	1-16-21909	NM

General Provider Information

NPI Number	:	1023471976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANE KNOLL

Provider Business Mailing Address
First Line	:	2892 PUEBLO BONITO
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87507-2549
Country	:	US
Telephone Number	:	508-665-8044
Fax Number	:

Provider Business Practice Location Address
First Line	:	2892 PUEBLO BONITO
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87507-2549
Country	:	US
Telephone Number	:	508-665-8044
Fax Number	:

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

Provider Enumeration Date	:	03/29/2016
Last Update Date	:	06/20/2016

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Directions to “ SHANE KNOLL ” Practice Location

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