MEDICARE: LEA ELMER 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	106S00000X	Behavior Technician
2	103K00000X	Behavior Analyst	1-21-48595	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1-21-48595	OTHER	CA	BACB

General Provider Information

NPI Number	:	1225539208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEA ELMER MED, BCBA

Provider Business Mailing Address
First Line	:	2423 HOOVER AVE
Second Line	:
City	:	NATIONAL CITY
State	:	CA
Zip	:	91950-6619
Country	:	US
Telephone Number	:	619-795-9925
Fax Number	:

Provider Business Practice Location Address
First Line	:	2423 HOOVER AVE
Second Line	:
City	:	NATIONAL CITY
State	:	CA
Zip	:	91950-6619
Country	:	US
Telephone Number	:	619-795-9925
Fax Number	:

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

Provider Enumeration Date	:	02/23/2018
Last Update Date	:	04/29/2022

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