MEDICARE: TRACIE ANDERSON 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	ABALBA00222174	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1-15-18299	OTHER	KY	BEHAVIOR ANALYSIS CERTIFICATION BOARD

General Provider Information

NPI Number	:	1407225881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACIE ANDERSON BCBA

Provider Business Mailing Address
First Line	:	8412 SABERDEE DR
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40242-3030
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1519 BAXTER AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40205-1008
Country	:	US
Telephone Number	:	502-409-7181
Fax Number	:

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

Provider Enumeration Date	:	09/16/2015
Last Update Date	:	09/16/2015

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Directions to “ TRACIE ANDERSON BCBA” Practice Location

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