MEDICARE: MOLLY MARIE WENDORF 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	:	1427550268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLY MARIE WENDORF BCBA

Provider Business Mailing Address
First Line	:	2285 W INA RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85741-2650
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2285 W INA RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85741-2650
Country	:	US
Telephone Number	:	520-484-1010
Fax Number	:

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

Provider Enumeration Date	:	03/07/2018
Last Update Date	:	09/09/2022

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