MEDICARE: MS. ANISSA LOUISE AUGUSTINE

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	:	1588025852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANISSA LOUISE AUGUSTINE

Provider Business Mailing Address
First Line	:	1906 S VRAIN ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80219-5033
Country	:	US
Telephone Number	:	586-242-3826
Fax Number	:

Provider Business Practice Location Address
First Line	:	1906 S VRAIN ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80219-5033
Country	:	US
Telephone Number	:	586-242-3826
Fax Number	:

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

Provider Enumeration Date	:	03/15/2016
Last Update Date	:	04/26/2019

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