MEDICARE: SAVANNAH NICOLE ROSE M.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	106S00000X	Behavior Technician	36790717	TX
2	103K00000X	Behavior Analyst	4406	TX

General Provider Information

NPI Number	:	1356820146
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAVANNAH NICOLE ROSE M.ED, BCBA

Provider Business Mailing Address
First Line	:	21600 OXNARD ST STE 1800
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91367-7807
Country	:	US
Telephone Number	:	818-345-2345
Fax Number	:

Provider Business Practice Location Address
First Line	:	6513 PRECINCT LINE RD # 200
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76182-4313
Country	:	US
Telephone Number	:	682-257-3531
Fax Number	:

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

Provider Enumeration Date	:	08/13/2018
Last Update Date	:	09/14/2021

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