MEDICARE: JULIETTE BACON 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	:	1417331836
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIETTE BACON BCBA

Provider Business Mailing Address
First Line	:	5580 E 2ND ST STE 101
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90803-3958
Country	:	US
Telephone Number	:	888-582-2974
Fax Number	:

Provider Business Practice Location Address
First Line	:	5580 E 2ND ST STE 101
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90803-3958
Country	:	US
Telephone Number	:	888-582-2974
Fax Number	:

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

Provider Enumeration Date	:	07/15/2015
Last Update Date	:	07/15/2015

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