MEDICARE: BRADLEY NEIL RUNSICK MS, 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	1-14-15531	CA

General Provider Information

NPI Number	:	1588065114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY NEIL RUNSICK MS, BCBA

Provider Business Mailing Address
First Line	:	1433 FOOTHILL BLVD
Second Line	:
City	:	LA CANADA
State	:	CA
Zip	:	91011-2109
Country	:	US
Telephone Number	:	714-273-4429
Fax Number	:	818-937-0883

Provider Business Practice Location Address
First Line	:	4712 E 2ND ST
Second Line	:	SUITE 140
City	:	LONG BEACH
State	:	CA
Zip	:	90803-5309
Country	:	US
Telephone Number	:	714-273-4429
Fax Number	:	818-937-0883

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

Provider Enumeration Date	:	09/15/2014
Last Update Date	:	08/09/2016

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