MEDICARE: THOMAS A ALTRO 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	1-16-22260

General Provider Information

NPI Number	:	1801223169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS A ALTRO BCBA

Provider Business Mailing Address
First Line	:	175 MIDDLE ST
Second Line	:	SUITE 1201
City	:	LAKE MARY
State	:	FL
Zip	:	32746-3625
Country	:	US
Telephone Number	:	866-610-0580
Fax Number	:	866-610-0580

Provider Business Practice Location Address
First Line	:	515 PALM COAST PKWY SW
Second Line	:	SUITE 6/7
City	:	PALM COAST
State	:	FL
Zip	:	32137-4739
Country	:	US
Telephone Number	:	386-951-3044
Fax Number	:	866-610-0580

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

Provider Enumeration Date	:	10/02/2013
Last Update Date	:	11/22/2016

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