MEDICARE: BEHAVIORAL LEARNING AGENCY

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	252Y00000X	Early Intervention Provider Agency	0-12-5059	TX

General Provider Information

NPI Number	:	1437588498
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEHAVIORAL LEARNING AGENCY

Provider Business Mailing Address
First Line	:	5739 BELVEDERE STREET
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77021
Country	:	US
Telephone Number	:	832-978-3474
Fax Number	:

Provider Business Practice Location Address
First Line	:	5739 BELVEDERE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77021-3201
Country	:	US
Telephone Number	:	832-978-3474
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	LAUREN MICHELLE WIGGINS
Credential	:
Telephone Number	:	832-978-3474

Provider Enumeration Date	:	11/10/2013
Last Update Date	:	11/10/2013

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