MEDICARE: LEEANN ROSE VANBEENEN

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	106E00000X	Assistant Behavior Analyst	Y2148208	CA
2	106S00000X	Behavior Technician	Y2148208	CA
3	103K00000X	Behavior Analyst	Y2148208	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447819685
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEEANN ROSE VANBEENEN

Provider Business Mailing Address
First Line	:	2489 LAKE TAHOE BLVD STE 23
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150-7739
Country	:	US
Telephone Number	:	530-578-3839
Fax Number	:

Provider Business Practice Location Address
First Line	:	2489 LAKE TAHOE BLVD
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150-7728
Country	:	US
Telephone Number	:	530-578-3839
Fax Number	:

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

Provider Enumeration Date	:	06/11/2019
Last Update Date	:	06/11/2019

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Directions to “ LEEANN ROSE VANBEENEN ” Practice Location

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