MEDICARE: ASHLEY DESANCTIS 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	120-140	WI

General Provider Information

NPI Number	:	1699130880
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEY DESANCTIS BCBA

Provider Business Mailing Address
First Line	:	1575 ALLOUEZ AVE
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-5639
Country	:	US
Telephone Number	:	920-857-9041
Fax Number	:	920-857-3366

Provider Business Practice Location Address
First Line	:	1575 ALLOUEZ AVE
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54311-5639
Country	:	US
Telephone Number	:	920-857-9041
Fax Number	:	920-857-3366

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

Provider Enumeration Date	:	12/15/2015
Last Update Date	:	12/15/2015

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Directions to “ ASHLEY DESANCTIS BCBA” Practice Location

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