MEDICARE: CODY CHARLES MEEHAN RBT

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	106S00000X	Behavior Technician
2	103K00000X	Behavior Analyst	2021047877	MO

General Provider Information

NPI Number	:	1992314041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CODY CHARLES MEEHAN RBT

Provider Business Mailing Address
First Line	:	1412 GRANDVIEW DR
Second Line	:
City	:	WARRENSBURG
State	:	MO
Zip	:	64093-9529
Country	:	US
Telephone Number	:	660-909-4225
Fax Number	:

Provider Business Practice Location Address
First Line	:	1508 NW VIVION RD
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64118-4557
Country	:	US
Telephone Number	:	636-893-7207
Fax Number	:

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

Provider Enumeration Date	:	07/24/2020
Last Update Date	:	12/06/2021

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