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NPI Code Detail

MEDICARE: EMILY DIANE ICE BCABA

MEDICARE: EMILY DIANE ICE 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
1103K00000XBehavior Analyst

General Provider Information

NPI Number : 1942452651
Entity Type Code : Individual
Provider Name (Legal Business Name) : EMILY DIANE ICE BCABA
Provider Business Mailing Address
First Line : 3060 AMBER AVE
Second Line :
City : FAIRBANKS
State : AK
Zip : 99709-4046
Country : US
Telephone Number : 907-347-8115
Fax Number :
Provider Business Practice Location Address
First Line : 3568 GERAGHTY AVE
Second Line :
City : FAIRBANKS
State : AK
Zip : 99709-4701
Country : US
Telephone Number : 907-347-8115
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/14/2008
Last Update Date : 08/27/2024

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Directions to “ EMILY DIANE ICE BCABA” Practice Location

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