MEDICARE: MRS. HOLLY ANNE BENNETT 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	1-12-12375	MD

General Provider Information

NPI Number	:	1184960122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HOLLY ANNE BENNETT M.S., BCBA

Provider Business Mailing Address
First Line	:	4606 WARDS CHAPEL RD
Second Line	:
City	:	OWINGS MILLS
State	:	MD
Zip	:	21117-4614
Country	:	US
Telephone Number	:	410-818-8942
Fax Number	:

Provider Business Practice Location Address
First Line	:	4606 WARDS CHAPEL RD
Second Line	:
City	:	OWINGS MILLS
State	:	MD
Zip	:	21117-4614
Country	:	US
Telephone Number	:	410-818-8942
Fax Number	:

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

Provider Enumeration Date	:	12/19/2012
Last Update Date	:	12/19/2012

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