MEDICARE: MS. HOLLY WELLS WILLBORN BA, BCAT, 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	RBT-16-19496	CO

General Provider Information

NPI Number	:	1053829069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. HOLLY WELLS WILLBORN BA, BCAT, RBT

Provider Business Mailing Address
First Line	:	21600 OXNARD ST STE 1800
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91367-7807
Country	:	US
Telephone Number	:	818-345-2345
Fax Number	:

Provider Business Practice Location Address
First Line	:	2121 S BLACKHAWK ST STE 100
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80014-1488
Country	:	US
Telephone Number	:	720-545-0768
Fax Number	:

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

Provider Enumeration Date	:	01/12/2018
Last Update Date	:	01/12/2018

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