MEDICARE: KATRINA RENEE FLEMISTER 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	3209	TX

General Provider Information

NPI Number	:	1588194609
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATRINA RENEE FLEMISTER BCBA

Provider Business Mailing Address
First Line	:	4537 HERITAGE TRACE PKWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-8921
Country	:	US
Telephone Number	:	817-442-0222
Fax Number	:

Provider Business Practice Location Address
First Line	:	4537 HERITAGE TRACE PKWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-8921
Country	:	US
Telephone Number	:	817-442-0222
Fax Number	:

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

Provider Enumeration Date	:	06/13/2017
Last Update Date	:	03/11/2020

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