MEDICARE: KRISTIN KORNELIK BCBA

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

General Provider Information

NPI Number	:	1093260192
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN KORNELIK BCBA

Provider Business Mailing Address
First Line	:	342 N WATER ST
Second Line	:	600
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-5514
Country	:	US
Telephone Number	:	844-263-1613
Fax Number	:	844-263-1612

Provider Business Practice Location Address
First Line	:	342 N WATER ST
Second Line	:	600
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-5514
Country	:	US
Telephone Number	:	844-263-1613
Fax Number	:	844-263-1612

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

Provider Enumeration Date	:	08/18/2016
Last Update Date	:	08/18/2016

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