MEDICARE: DANIELLE BRASSARD 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	106S00000X	Behavior Technician
2	103K00000X	Behavior Analyst	1-21-49347	IN

General Provider Information

NPI Number	:	1336622315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELLE BRASSARD BCBA

Provider Business Mailing Address
First Line	:	239 E WINSLOW RD
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47401-8638
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	239 E WINSLOW RD
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47401-8638
Country	:	US
Telephone Number	:	812-287-8561
Fax Number	:

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

Provider Enumeration Date	:	09/14/2018
Last Update Date	:	10/19/2022

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