=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639820665
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL SCOTT FEESER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2022
-----------------------------------------------------
Last Update Date | 09/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 911 BERN CT STE 130
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95112-1242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-437-8864
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4086 TENITA DR
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32792-8944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-844-7298
-----------------------------------------------------
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-21-184776
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2355S0801X
-----------------------------------------------------
Taxonomy Name | Speech-Language Assistant
-----------------------------------------------------
License Number | 5391
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2355S0801X
-----------------------------------------------------
Taxonomy Name | Speech-Language Assistant
-----------------------------------------------------
License Number | 9038
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------