MEDICARE: MEGAN ELIZABETH SIMONICH

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	106E00000X	Assistant Behavior Analyst		CA

General Provider Information

NPI Number	:	1770231268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEGAN ELIZABETH SIMONICH

Provider Business Mailing Address
First Line	:	1219 BOND ST
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93405-1928
Country	:	US
Telephone Number	:	559-802-8649
Fax Number	:

Provider Business Practice Location Address
First Line	:	1219 BOND ST
Second Line	:
City	:	SAN LUIS OBISPO
State	:	CA
Zip	:	93405-1928
Country	:	US
Telephone Number	:	559-802-8649
Fax Number	:

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

Provider Enumeration Date	:	03/14/2022
Last Update Date	:	03/14/2022

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