MEDICARE: MELISSA LYNN WAMBLE 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	1-22-60566

General Provider Information

NPI Number	:	1295457026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA LYNN WAMBLE BCBA

Provider Business Mailing Address
First Line	:	7108 S KANNER HWY
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34997-7462
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2526 SE CALADIUM AVE
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-7213
Country	:	US
Telephone Number	:	302-685-0066
Fax Number	:

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

Provider Enumeration Date	:	09/19/2022
Last Update Date	:	09/19/2022

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