MEDICARE: MRS. MARY A SMITH BCABA

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	0-07-2350

General Provider Information

NPI Number	:	1881920122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY A SMITH BCABA

Provider Business Mailing Address
First Line	:	302 WESLEY ST STE 1
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-1741
Country	:	US
Telephone Number	:	423-282-1700
Fax Number	:	423-282-9319

Provider Business Practice Location Address
First Line	:	302 WESLEY ST STE 1
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-1741
Country	:	US
Telephone Number	:	423-282-1700
Fax Number	:	423-282-9319

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

Provider Enumeration Date	:	10/21/2009
Last Update Date	:	10/21/2009

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