MEDICARE: VICKI LYNN NIEDERMAYER 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	103TB0200X	Cognitive & Behavioral Psychologist	1-07-3381	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1-07-3381	OTHER	TX	BOARD CERT. BEH.ANALYST

General Provider Information

NPI Number	:	1083817357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICKI LYNN NIEDERMAYER BCBA

Provider Business Mailing Address
First Line	:	5801 GLOUCESTER CT
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76018-2384
Country	:	US
Telephone Number	:	817-690-7218
Fax Number	:

Provider Business Practice Location Address
First Line	:	5801 GLOUCESTER CT
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76018-2384
Country	:	US
Telephone Number	:	817-690-7218
Fax Number	:

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

Provider Enumeration Date	:	06/06/2007
Last Update Date	:	07/08/2007

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