MEDICARE: KASEY MOMIER

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	106S00000X	Behavior Technician	18-54245	FL

General Provider Information

NPI Number	:	1912491580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KASEY MOMIER

Provider Business Mailing Address
First Line	:	2580 LIN DO CT
Second Line	:
City	:	SUMTER
State	:	SC
Zip	:	29150-1832
Country	:	US
Telephone Number	:	803-905-4427
Fax Number	:	803-905-4431

Provider Business Practice Location Address
First Line	:	1040 FERNWOOD GLENDALE RD STE 62
Second Line	:
City	:	SPARTANBURG
State	:	SC
Zip	:	29307-2336
Country	:	US
Telephone Number	:	864-214-2061
Fax Number	:

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

Provider Enumeration Date	:	06/18/2018
Last Update Date	:	06/18/2018

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