MEDICARE: JODIE ILENE MIENTKIEWICZ 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	1-17-26866	MI

General Provider Information

NPI Number	:	1932600186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JODIE ILENE MIENTKIEWICZ BCBA

Provider Business Mailing Address
First Line	:	28116 ORCHARD LAKE RD
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-3737
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	28116 ORCHARD LAKE RD
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-3737
Country	:	US
Telephone Number	:	248-550-0333
Fax Number	:

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

Provider Enumeration Date	:	02/23/2018
Last Update Date	:	02/23/2018

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