MEDICARE: ELAINE ROSEMARY ROLLER B.A.

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	:	1093402141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELAINE ROSEMARY ROLLER B.A.

Provider Business Mailing Address
First Line	:	PO BOX 2916
Second Line	:
City	:	VICTORVILLE
State	:	CA
Zip	:	92393-2916
Country	:	US
Telephone Number	:	442-353-9887
Fax Number	:

Provider Business Practice Location Address
First Line	:	27252 JACKSON RD
Second Line	:
City	:	APPLE VALLEY
State	:	CA
Zip	:	92307-6632
Country	:	US
Telephone Number	:	442-353-9887
Fax Number	:

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

Provider Enumeration Date	:	04/19/2023
Last Update Date	:	04/19/2023

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