MEDICARE: CARAVEL AUTISM HEALTH, LLC

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	103TC0700X	Clinical Psychologist	1871-57	WI
2	103K00000X	Behavior Analyst	1-08-4429	WI

General Provider Information

NPI Number	:	1588993091
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARAVEL AUTISM HEALTH, LLC

Provider Business Mailing Address
First Line	:	1575 ALLOUEZ AVE
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-5639
Country	:	US
Telephone Number	:	920-857-9041
Fax Number	:	920-857-3366

Provider Business Practice Location Address
First Line	:	1575 ALLOUEZ AVE
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-5639
Country	:	US
Telephone Number	:	920-857-9041
Fax Number	:	920-857-3366

Authorized Official
Title or Position	:	PRESIDENT/CCO
Name	:	DR. ERIC JOHN LUND
Credential	:	PSY.D. BCBA ABPP
Telephone Number	:	920-857-2577

Provider Enumeration Date	:	12/11/2009
Last Update Date	:	01/14/2016

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Directions to “CARAVEL AUTISM HEALTH, LLC ” Practice Location

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