MEDICARE: JUSTIN MICHAEL WERTZ 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	1-21-55896

General Provider Information

NPI Number	:	1255989026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN MICHAEL WERTZ BCBA

Provider Business Mailing Address
First Line	:	1205 ADDYBROOK ST
Second Line	:
City	:	CONWAY
State	:	AR
Zip	:	72032-5838
Country	:	US
Telephone Number	:	501-514-2033
Fax Number	:

Provider Business Practice Location Address
First Line	:	2207 COTTONDALE LN STE 2
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72202-2018
Country	:	US
Telephone Number	:	501-539-3553
Fax Number	:

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

Provider Enumeration Date	:	08/26/2019
Last Update Date	:	10/11/2024

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