MEDICARE: SHELBY MARIE MINER BCABA

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	1-15-18824
2	103K00000X	Behavior Analyst	BCABA: 0-11-4018	CA

General Provider Information

NPI Number	:	1003104217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELBY MARIE MINER BCABA

Provider Business Mailing Address
First Line	:	PO BOX 33568
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92163-3568
Country	:	US
Telephone Number	:	855-223-7123
Fax Number	:	619-374-7134

Provider Business Practice Location Address
First Line	:	725 S MESA HILLS DR BLDG 3
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-5568
Country	:	US
Telephone Number	:	800-515-5016
Fax Number	:	619-374-7134

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

Provider Enumeration Date	:	07/21/2011
Last Update Date	:	04/25/2023

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Directions to “ SHELBY MARIE MINER BCABA” Practice Location

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