MEDICARE: ANGELA MCCOMAS 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	1-20-46639	IN

General Provider Information

NPI Number	:	1255923405
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA MCCOMAS BCBA

Provider Business Mailing Address
First Line	:	343 W SUTTENFIELD ST
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46807-1339
Country	:	US
Telephone Number	:	260-255-3665
Fax Number	:	260-255-3594

Provider Business Practice Location Address
First Line	:	201 E RUDISILL BLVD STE B100
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46806-1738
Country	:	US
Telephone Number	:	260-255-3665
Fax Number	:	260-255-3594

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

Provider Enumeration Date	:	02/09/2021
Last Update Date	:	02/09/2021

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