MEDICARE: ELEANOR MANDT MA, 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	1134-140	WI

General Provider Information

NPI Number	:	1164208351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELEANOR MANDT MA, BCBA

Provider Business Mailing Address
First Line	:	4005 FELLAND RD STE 102
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53718-6461
Country	:	US
Telephone Number	:	608-471-5089
Fax Number	:

Provider Business Practice Location Address
First Line	:	4005 FELLAND RD STE 102
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53718-6461
Country	:	US
Telephone Number	:	608-471-5089
Fax Number	:

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

Provider Enumeration Date	:	09/05/2023
Last Update Date	:	09/05/2023

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