MEDICARE: KENNETH PAUL EWERT 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	106S00000X	Behavior Technician
2	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1962023481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH PAUL EWERT BCBA

Provider Business Mailing Address
First Line	:	306 N KENSINGTON AVE
Second Line	:
City	:	LA GRANGE PARK
State	:	IL
Zip	:	60526-1870
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3131 S NEVADA ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53207-2827
Country	:	US
Telephone Number	:	312-965-2997
Fax Number	:

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

Provider Enumeration Date	:	05/06/2020
Last Update Date	:	04/28/2025

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