MEDICARE: MELISSA DEJESUS RBT

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

General Provider Information

NPI Number	:	1427565431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA DEJESUS RBT

Provider Business Mailing Address
First Line	:	7641 CANYON OAK DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80922-6319
Country	:	US
Telephone Number	:	321-890-4577
Fax Number	:

Provider Business Practice Location Address
First Line	:	240 WRITERS WAY
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-6214
Country	:	US
Telephone Number	:	719-248-4122
Fax Number	:

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

Provider Enumeration Date	:	12/29/2017
Last Update Date	:	12/29/2017

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