MEDICARE: MR. ADAM LEE ALLEN M.S., 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	1-18-31067	GA

General Provider Information

NPI Number	:	1114412863
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ADAM LEE ALLEN M.S., BCBA

Provider Business Mailing Address
First Line	:	2824 HILLCREEK DR
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-5628
Country	:	US
Telephone Number	:	706-826-2770
Fax Number	:	706-826-2771

Provider Business Practice Location Address
First Line	:	2824 HILLCREEK DR
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909
Country	:	US
Telephone Number	:	706-826-2770
Fax Number	:	706-826-2771

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

Provider Enumeration Date	:	06/26/2018
Last Update Date	:	06/26/2018

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