MEDICARE: CHRISNICOLAS PAUL KEITH

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	106S00000X	Behavior Technician	23-4210-619985	TX

General Provider Information

NPI Number	:	1205608270
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISNICOLAS PAUL KEITH

Provider Business Mailing Address
First Line	:	234 W BANDERA RD # 325
Second Line	:
City	:	BOERNE
State	:	TX
Zip	:	78006-2805
Country	:	US
Telephone Number	:	210-447-7041
Fax Number	:	866-403-7980

Provider Business Practice Location Address
First Line	:	2525 LADD ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78236-5308
Country	:	US
Telephone Number	:	210-447-7041
Fax Number	:	866-403-7980

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

Provider Enumeration Date	:	10/24/2023
Last Update Date	:	10/24/2023

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Directions to “ CHRISNICOLAS PAUL KEITH ” Practice Location

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