MEDICARE: SPENCER GRADY BYRD

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	:	1740536945
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SPENCER GRADY BYRD

Provider Business Mailing Address
First Line	:	4217 NE LAUREL DR
Second Line	:
City	:	ADAIR VILLAGE
State	:	OR
Zip	:	97330-9479
Country	:	US
Telephone Number	:	541-207-7235
Fax Number	:

Provider Business Practice Location Address
First Line	:	4217 NE LAUREL DR
Second Line	:
City	:	ADAIR VILLAGE
State	:	OR
Zip	:	97330-9479
Country	:	US
Telephone Number	:	541-207-7235
Fax Number	:

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

Provider Enumeration Date	:	07/25/2012
Last Update Date	:	07/25/2012

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Directions to “ SPENCER GRADY BYRD ” Practice Location

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