MEDICARE: JUSTINE ERICA PANCHUK 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619565702
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTINE ERICA PANCHUK BCBA

Provider Business Mailing Address
First Line	:	PO BOX 10827
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32302-2827
Country	:	US
Telephone Number	:	850-521-0242
Fax Number	:

Provider Business Practice Location Address
First Line	:	3223 NW 10TH TER STE 610
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33309-5940
Country	:	US
Telephone Number	:	431-276-0954
Fax Number	:

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

Provider Enumeration Date	:	01/05/2021
Last Update Date	:	11/01/2022

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