MEDICARE: ANA P HERT BCABA

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	0-11-4176	FL

General Provider Information

NPI Number	:	1366884009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANA P HERT BCABA

Provider Business Mailing Address
First Line	:	3771 SAN JOSE PL
Second Line	:	STE. 22
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-2436
Country	:	US
Telephone Number	:	904-928-0112
Fax Number	:	904-928-0112

Provider Business Practice Location Address
First Line	:	3771 SAN JOSE PL
Second Line	:	STE. 22
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-2436
Country	:	US
Telephone Number	:	904-928-0112
Fax Number	:	904-928-0112

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

Provider Enumeration Date	:	07/23/2013
Last Update Date	:	07/23/2013

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