MEDICARE: ALEXANDRA GARRETT 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	1-19-35650	UT

General Provider Information

NPI Number	:	1295208163
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDRA GARRETT BCBA

Provider Business Mailing Address
First Line	:	10175 FORTUNE PKWY UNIT 903
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-6755
Country	:	US
Telephone Number	:	904-538-0713
Fax Number	:

Provider Business Practice Location Address
First Line	:	365 W 1550 N STE F
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-2279
Country	:	US
Telephone Number	:	801-876-5809
Fax Number	:

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

Provider Enumeration Date	:	01/03/2019
Last Update Date	:	02/12/2020

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