MEDICARE: KELLY WEEDON NODA 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	0-17-8186
2	222Q00000X	Developmental Therapist
3	103K00000X	Behavior Analyst	1-17-29567	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093261737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY WEEDON NODA BCBA

Provider Business Mailing Address
First Line	:	13121 ATLANTIC BLVD STE 200
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-0102
Country	:	US
Telephone Number	:	904-491-2111
Fax Number	:

Provider Business Practice Location Address
First Line	:	13121 ATLANTIC BLVD STE 200
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-0102
Country	:	US
Telephone Number	:	904-491-2111
Fax Number	:

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

Provider Enumeration Date	:	09/01/2016
Last Update Date	:	03/24/2018

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Directions to “ KELLY WEEDON NODA BCBA” Practice Location

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