MEDICARE: MEGAN ROSE WILCOTT

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	BA-157	AZ

General Provider Information

NPI Number	:	1740672096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEGAN ROSE WILCOTT

Provider Business Mailing Address
First Line	:	300 N 18TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85006-4103
Country	:	US
Telephone Number	:	602-340-8717
Fax Number	:

Provider Business Practice Location Address
First Line	:	2225 N 16TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85006-1823
Country	:	US
Telephone Number	:	602-218-8217
Fax Number	:

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

Provider Enumeration Date	:	02/24/2015
Last Update Date	:	02/24/2015

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