MEDICARE: MRS. GRACE MARTIN SIMUNEK M.ED, 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	1-14-15400	NC

General Provider Information

NPI Number	:	1659786531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GRACE MARTIN SIMUNEK M.ED, BCBA

Provider Business Mailing Address
First Line	:	4548 EMORY LN
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-2435
Country	:	US
Telephone Number	:	774-930-9246
Fax Number	:

Provider Business Practice Location Address
First Line	:	4548 EMORY LN
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-2435
Country	:	US
Telephone Number	:	774-930-9246
Fax Number	:

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

Provider Enumeration Date	:	06/30/2014
Last Update Date	:	02/02/2015

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