MEDICARE: IDALIAS MELIA SAMSON PALMER 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	1-26-87398	CO

General Provider Information

NPI Number	:	1477101517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IDALIAS MELIA SAMSON PALMER BCBA

Provider Business Mailing Address
First Line	:	7237 MAYBECK VW
Second Line	:
City	:	PEYTON
State	:	CO
Zip	:	80831-4739
Country	:	US
Telephone Number	:	719-761-4189
Fax Number	:

Provider Business Practice Location Address
First Line	:	5165 BALSAM ST
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80923-5144
Country	:	US
Telephone Number	:	719-425-8702
Fax Number	:

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

Provider Enumeration Date	:	09/02/2019
Last Update Date	:	03/26/2026

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