MEDICARE: ASHLEE KEUNEKE 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

General Provider Information

NPI Number	:	1821334624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEE KEUNEKE BCBA

Provider Business Mailing Address
First Line	:	PO BOX 10343
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46851-0343
Country	:	US
Telephone Number	:	888-667-1181
Fax Number	:	888-265-7858

Provider Business Practice Location Address
First Line	:	2270 LAKE AVE
Second Line	:	SUITE 101
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-5359
Country	:	US
Telephone Number	:	888-667-1181
Fax Number	:	888-265-7858

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

Provider Enumeration Date	:	12/26/2012
Last Update Date	:	12/26/2012

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