MEDICARE: XAVIER NATHANIEL HUNTER

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	F4498482	CA
2	106E00000X	Assistant Behavior Analyst		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	XDP923A75466	OTHER	CA	ANTHEM BLUE CROSS

General Provider Information

NPI Number	:	1902326390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	XAVIER NATHANIEL HUNTER

Provider Business Mailing Address
First Line	:	PO BOX 5157
Second Line	:
City	:	MODESTO
State	:	CA
Zip	:	95352-5157
Country	:	US
Telephone Number	:	209-572-2589
Fax Number	:	209-353-3353

Provider Business Practice Location Address
First Line	:	4196 DOUGLAS BLVD STE 100
Second Line	:
City	:	GRANITE BAY
State	:	CA
Zip	:	95746-5904
Country	:	US
Telephone Number	:	916-489-1376
Fax Number	:

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

Provider Enumeration Date	:	06/27/2017
Last Update Date	:	06/23/2020

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