MEDICARE: ELIZABETH TICE MS 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	1-13-14729	MA
2	103K00000X	Behavior Analyst	543	MA

General Provider Information

NPI Number	:	1942672506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH TICE MS BCBA LABA

Provider Business Mailing Address
First Line	:	656 MAYFLOWER ST
Second Line	:
City	:	DUXBURY
State	:	MA
Zip	:	02332-3617
Country	:	US
Telephone Number	:	973-768-4356
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 ROCHE BROTHERS WAY STE 6-381
Second Line	:
City	:	NORTH EASTON
State	:	MA
Zip	:	02356-1030
Country	:	US
Telephone Number	:	855-832-6727
Fax Number	:	772-675-9100

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

Provider Enumeration Date	:	10/22/2015
Last Update Date	:	10/21/2024

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