MEDICARE: MS. PHYLLIS APPLE SAMPLE B.C.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	174400000X	Specialist	BACB # 1-06-2656	TX

General Provider Information

NPI Number	:	1184809881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PHYLLIS APPLE SAMPLE B.C.B.A.

Provider Business Mailing Address
First Line	:	4015 SABLE OAKS DR
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78664-6254
Country	:	US
Telephone Number	:	512-248-0644
Fax Number	:

Provider Business Practice Location Address
First Line	:	4015 SABLE OAKS DR
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78664-6254
Country	:	US
Telephone Number	:	512-248-0644
Fax Number	:

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

Provider Enumeration Date	:	01/01/2008
Last Update Date	:	01/01/2008

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Directions to “ MS. PHYLLIS APPLE SAMPLE B.C.B.A.” Practice Location

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