MEDICARE: KAITLYN LORRAINE DVORAK

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	:	1215579636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLYN LORRAINE DVORAK

Provider Business Mailing Address
First Line	:	731 BIELENBERG DR STE 102-104
Second Line	:
City	:	WOODBURY
State	:	MN
Zip	:	55125-1700
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	731 BIELENBERG DR STE 102-104
Second Line	:
City	:	WOODBURY
State	:	MN
Zip	:	55125-1700
Country	:	US
Telephone Number	:	612-439-4653
Fax Number	:

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

Provider Enumeration Date	:	10/17/2019
Last Update Date	:	02/06/2024

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