MEDICARE: EMILY STODDARD BCBA

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	1-20-41291	OH

General Provider Information

NPI Number	:	1790304210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY STODDARD BCBA

Provider Business Mailing Address
First Line	:	805 E WASHINGTON ST STE 130
Second Line	:
City	:	MEDINA
State	:	OH
Zip	:	44256-3331
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	805 E WASHINGTON ST STE 130
Second Line	:
City	:	MEDINA
State	:	OH
Zip	:	44256-3331
Country	:	US
Telephone Number	:	234-255-8531
Fax Number	:

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

Provider Enumeration Date	:	04/14/2020
Last Update Date	:	09/16/2022

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Directions to “ EMILY STODDARD BCBA” Practice Location

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