MEDICARE: MAGGIE MARIE KURTZUBA 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	1-17-27869

General Provider Information

NPI Number	:	1669982518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAGGIE MARIE KURTZUBA BCBA

Provider Business Mailing Address
First Line	:	2805 LINKSWILLER RD
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70607-7573
Country	:	US
Telephone Number	:	318-554-8348
Fax Number	:	866-399-7694

Provider Business Practice Location Address
First Line	:	4019 COMMON ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70607-2942
Country	:	US
Telephone Number	:	337-377-6206
Fax Number	:

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

Provider Enumeration Date	:	10/05/2017
Last Update Date	:	10/05/2017

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