MEDICARE: SOPHIA HELEN PELICH BCBA LABA

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	2613	MA

General Provider Information

NPI Number	:	1891255667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOPHIA HELEN PELICH BCBA LABA

Provider Business Mailing Address
First Line	:	2 ADRIAN ST
Second Line	:
City	:	NORTH ANDOVER
State	:	MA
Zip	:	01845-5402
Country	:	US
Telephone Number	:	978-697-4415
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 ADRIAN ST
Second Line	:
City	:	NORTH ANDOVER
State	:	MA
Zip	:	01845-5402
Country	:	US
Telephone Number	:	978-697-4415
Fax Number	:

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

Provider Enumeration Date	:	03/20/2019
Last Update Date	:	03/20/2019

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