MEDICARE: KOMAL NOORDIN 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

General Provider Information

NPI Number	:	1295243467
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KOMAL NOORDIN BCBA

Provider Business Mailing Address
First Line	:	3180 PROFESSIONAL PLZ STE 101
Second Line	:
City	:	GERMANTOWN
State	:	TN
Zip	:	38138-1534
Country	:	US
Telephone Number	:	901-328-2110
Fax Number	:	901-328-1360

Provider Business Practice Location Address
First Line	:	3180 PROFESSIONAL PLZ STE 101
Second Line	:
City	:	GERMANTOWN
State	:	TN
Zip	:	38138-1534
Country	:	US
Telephone Number	:	901-328-2110
Fax Number	:	901-328-1360

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

Provider Enumeration Date	:	01/22/2018
Last Update Date	:	01/22/2018

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Directions to “ KOMAL NOORDIN BCBA” Practice Location

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