MEDICARE: EQUENCE NICOLE BYNUM MED, 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	1-23-65191	GA

General Provider Information

NPI Number	:	1194412189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EQUENCE NICOLE BYNUM MED, BCBA

Provider Business Mailing Address
First Line	:	650 FULLIER CIR SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-7993
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	650 FULLIER CIR SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-7993
Country	:	US
Telephone Number	:	404-664-9406
Fax Number	:

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

Provider Enumeration Date	:	04/19/2023
Last Update Date	:	04/19/2023

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