MEDICARE: LISA BRANCHAUD

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	0133000561	VA

General Provider Information

NPI Number	:	1265812143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA BRANCHAUD

Provider Business Mailing Address
First Line	:	4532 NORMAN RD
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23703-4925
Country	:	US
Telephone Number	:	757-651-2655
Fax Number	:	757-651-2655

Provider Business Practice Location Address
First Line	:	4532 NORMAN RD
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23703-4925
Country	:	US
Telephone Number	:	757-651-2655
Fax Number	:	757-651-2655

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

Provider Enumeration Date	:	06/04/2015
Last Update Date	:	06/04/2015

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