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NPI Code Detail

MEDICARE: MS. RADIAH MICHELLE WILSON M.ED., BCBA, LBA

MEDICARE: MS. RADIAH MICHELLE WILSON M.ED., BCBA, LBA
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
1222Q00000XDevelopmental Therapist010112115LA
2103K00000XBehavior AnalystL-241LA

General Provider Information

NPI Number : 1144574641
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. RADIAH MICHELLE WILSON M.ED., BCBA, LBA
Provider Business Mailing Address
First Line : 500 FAIRWAY DR STE 102
Second Line :
City : DEERFIELD BEACH
State : FL
Zip : 33441-1817
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 4201 N I 10 SERVICE RD W
Second Line :
City : METAIRIE
State : LA
Zip : 70006-6713
Country : US
Telephone Number : 855-550-5308
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/05/2012
Last Update Date : 03/17/2018

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