MEDICARE: KASEY MILLER ROSS 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	11623896	NJ

General Provider Information

NPI Number	:	1679076400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KASEY MILLER ROSS BCBA

Provider Business Mailing Address
First Line	:	60 FERRY RD
Second Line	:
City	:	STOCKTON
State	:	NJ
Zip	:	08559-1003
Country	:	US
Telephone Number	:	908-246-0448
Fax Number	:

Provider Business Practice Location Address
First Line	:	60 FERRY RD
Second Line	:
City	:	STOCKTON
State	:	NJ
Zip	:	08559-1003
Country	:	US
Telephone Number	:	908-246-0448
Fax Number	:

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

Provider Enumeration Date	:	03/18/2018
Last Update Date	:	03/18/2018

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