MEDICARE: ST NICHOLAS CENTER FOR EARLY INTERVENTION

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

General Provider Information

NPI Number	:	1740503952
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST NICHOLAS CENTER FOR EARLY INTERVENTION

Provider Business Mailing Address
First Line	:	519 CLARENCE ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-5205
Country	:	US
Telephone Number	:	337-656-2561
Fax Number	:	337-656-2562

Provider Business Practice Location Address
First Line	:	343 BROAD ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-4223
Country	:	US
Telephone Number	:	337-656-2561
Fax Number	:	337-656-2562

Authorized Official
Title or Position	:	HEAD OF BOARD
Name	:	CHRISTY JONES
Credential	:
Telephone Number	:	337-656-2561

Provider Enumeration Date	:	03/03/2010
Last Update Date	:	03/03/2010

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