MEDICARE: BRANDALYN M NEW 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	:	1508376047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDALYN M NEW BCBA

Provider Business Mailing Address
First Line	:	1311 HARMONY CHURCH RD
Second Line	:
City	:	COLQUITT
State	:	GA
Zip	:	39837
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	220 RIVER ST
Second Line	:
City	:	BAINBRIDGE
State	:	GA
Zip	:	39817-3654
Country	:	US
Telephone Number	:	256-926-8246
Fax Number	:

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

Provider Enumeration Date	:	10/11/2017
Last Update Date	:	10/07/2021

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