MEDICARE: LISA KAY PEDERSON

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1760907695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA KAY PEDERSON

Provider Business Mailing Address
First Line	:	1167 HILLSBORO MILE APT 206
Second Line	:
City	:	HILLSBORO BEACH
State	:	FL
Zip	:	33062-1600
Country	:	US
Telephone Number	:	954-319-3055
Fax Number	:

Provider Business Practice Location Address
First Line	:	1167 HILLSBORO MILE APT 206
Second Line	:
City	:	HILLSBORO BEACH
State	:	FL
Zip	:	33062-1600
Country	:	US
Telephone Number	:	954-319-3055
Fax Number	:

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

Provider Enumeration Date	:	08/11/2017
Last Update Date	:	07/21/2022

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