MEDICARE: MRS. MARY CATHERINE MCWILLIAMS

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	:	1750730529
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY CATHERINE MCWILLIAMS

Provider Business Mailing Address
First Line	:	873 SW COMMONWEALTH RD
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-2350
Country	:	US
Telephone Number	:	908-809-2112
Fax Number	:

Provider Business Practice Location Address
First Line	:	1515 INDIAN RIVER BLVD
Second Line	:	STE A210
City	:	VERO BEACH
State	:	FL
Zip	:	32960-5639
Country	:	US
Telephone Number	:	772-774-8224
Fax Number	:

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

Provider Enumeration Date	:	06/12/2016
Last Update Date	:	06/12/2016

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