MEDICARE: WHITNIE WOLSEY BCBA, LBA

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	103TB0200X	Cognitive & Behavioral Psychologist
2	103K00000X	Behavior Analyst	265716	KY

General Provider Information

NPI Number	:	1477034627
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WHITNIE WOLSEY BCBA, LBA

Provider Business Mailing Address
First Line	:	632 NELSON RD
Second Line	:
City	:	RUSSELL SPRINGS
State	:	KY
Zip	:	42642-7950
Country	:	US
Telephone Number	:	606-416-4194
Fax Number	:

Provider Business Practice Location Address
First Line	:	2443 LAKEWAY DRIVE
Second Line	:
City	:	RUSSELL SPRINGS
State	:	KY
Zip	:	42642-4264
Country	:	US
Telephone Number	:	606-416-4194
Fax Number	:

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

Provider Enumeration Date	:	08/26/2018
Last Update Date	:	09/02/2020

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