=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578349221
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERRA ANN FRASER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2023
-----------------------------------------------------
Last Update Date | 10/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 MITAD CIR
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32095-7445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-747-2904
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 680 TIMBERMILL LN
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32065-2231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-707-1266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-23-293774
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------