MEDICARE: MIRELLA PALAZZOLO MA, 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	1-20-46530	GA
2	247200000X	Other Technician	RBT-17-46916	GA

General Provider Information

NPI Number	:	1356950828
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRELLA PALAZZOLO MA, BCBA

Provider Business Mailing Address
First Line	:	300 INTERNATIONAL PKWY STE 200
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-5028
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5461 HILLANDALE DR STE 100
Second Line	:
City	:	LITHONIA
State	:	GA
Zip	:	30058-4842
Country	:	US
Telephone Number	:	470-361-2976
Fax Number	:

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

Provider Enumeration Date	:	07/30/2020
Last Update Date	:	06/10/2026

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