MEDICARE: BRIAN TANENBAUM 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	1-15-18571	CA

General Provider Information

NPI Number	:	1912384660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN TANENBAUM BCBA

Provider Business Mailing Address
First Line	:	2808 MCKINNEY AVE
Second Line	:	APT. 640
City	:	DALLAS
State	:	TX
Zip	:	75204-8603
Country	:	US
Telephone Number	:	214-789-1387
Fax Number	:

Provider Business Practice Location Address
First Line	:	2808 MCKINNEY AVE
Second Line	:	APT. 640
City	:	DALLAS
State	:	TX
Zip	:	75204-8603
Country	:	US
Telephone Number	:	214-789-1387
Fax Number	:

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

Provider Enumeration Date	:	05/01/2015
Last Update Date	:	08/18/2016

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