MEDICARE: SAVANNAH R BACON

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	:	1821771882
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAVANNAH R BACON

Provider Business Mailing Address
First Line	:	446 W MAPLE AVE APT 1
Second Line	:
City	:	BOUND BROOK
State	:	NJ
Zip	:	08805-1246
Country	:	US
Telephone Number	:	609-218-9330
Fax Number	:

Provider Business Practice Location Address
First Line	:	2780 MORRIS AVE STE 1B
Second Line	:
City	:	UNION
State	:	NJ
Zip	:	07083-4848
Country	:	US
Telephone Number	:	877-222-0399
Fax Number	:

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

Provider Enumeration Date	:	08/08/2023
Last Update Date	:	08/08/2023

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Directions to “ SAVANNAH R BACON ” Practice Location

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