MEDICARE: MRS. TERESE P DANA BC ABA

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11314501	OTHER		AETNA

General Provider Information

NPI Number	:	1306110499
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TERESE P DANA BC ABA

Provider Business Mailing Address
First Line	:	PO BOX 434
Second Line	:
City	:	FRYEBURG
State	:	ME
Zip	:	04037
Country	:	US
Telephone Number	:	207-935-1092
Fax Number	:	207-935-1092

Provider Business Practice Location Address
First Line	:	2069 VILLAGE RD
Second Line	:	MADISON ELEMENTARY SCHOOL
City	:	MADISON
State	:	NH
Zip	:	03849
Country	:	US
Telephone Number	:	603-367-4642
Fax Number	:	603-367-8784

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

Provider Enumeration Date	:	03/07/2012
Last Update Date	:	11/25/2013

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