MEDICARE: MADELON KOLOVICH

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

General Provider Information

NPI Number	:	1215310305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADELON KOLOVICH

Provider Business Mailing Address
First Line	:	3601 KERNAN BLVD S
Second Line	:	1411
City	:	JACKSONVILLE
State	:	FL
Zip	:	32224-9602
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9141 CYPRESS GREEN DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-2013
Country	:	US
Telephone Number	:	904-647-1849
Fax Number	:

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

Provider Enumeration Date	:	07/07/2015
Last Update Date	:	07/07/2015

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