MEDICARE: ANDREA S VINNING 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	222Q00000X	Developmental Therapist
2	103K00000X	Behavior Analyst	1-21-55829	LA

General Provider Information

NPI Number	:	1497107346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA S VINNING BCBA

Provider Business Mailing Address
First Line	:	9305 MAIN ST STE E
Second Line	:
City	:	ZACHARY
State	:	LA
Zip	:	70791-7441
Country	:	US
Telephone Number	:	225-278-1020
Fax Number	:

Provider Business Practice Location Address
First Line	:	9305 MAIN ST STE E
Second Line	:
City	:	ZACHARY
State	:	LA
Zip	:	70791-7441
Country	:	US
Telephone Number	:	225-278-1020
Fax Number	:

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

Provider Enumeration Date	:	07/04/2016
Last Update Date	:	03/28/2022

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