MEDICARE: MS. MELANIE BETH WAGNER M.S.ED., 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	:	1346477510
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MELANIE BETH WAGNER M.S.ED., BCBA

Provider Business Mailing Address
First Line	:	12061 STONE CROSSING CIRCLE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33635
Country	:	US
Telephone Number	:	813-957-0866
Fax Number	:

Provider Business Practice Location Address
First Line	:	12061 STONE CROSSING CIR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33635-6228
Country	:	US
Telephone Number	:	813-957-0866
Fax Number	:

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

Provider Enumeration Date	:	06/16/2009
Last Update Date	:	06/16/2009

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