MEDICARE: GISELE LUCETTE MYRICK

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1609530351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GISELE LUCETTE MYRICK

Provider Business Mailing Address
First Line	:	1607 DYESS CT
Second Line	:
City	:	SCOTT AIR FORCE BASE
State	:	IL
Zip	:	62225-6330
Country	:	US
Telephone Number	:	717-350-5850
Fax Number	:

Provider Business Practice Location Address
First Line	:	1716 CORPORATE XING STE 3
Second Line	:
City	:	O FALLON
State	:	IL
Zip	:	62269-3734
Country	:	US
Telephone Number	:	844-244-1818
Fax Number	:

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

Provider Enumeration Date	:	10/28/2021
Last Update Date	:	10/28/2021

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Directions to “ GISELE LUCETTE MYRICK ” Practice Location

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