MEDICARE: MISS JULIA MYRIAH GARDELLA-FORTIER

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

General Provider Information

NPI Number	:	1962793448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JULIA MYRIAH GARDELLA-FORTIER

Provider Business Mailing Address
First Line	:	190 E 7TH ST
Second Line	:	APT 416
City	:	NEW YORK
State	:	NY
Zip	:	10009-5975
Country	:	US
Telephone Number	:	617-519-9685
Fax Number	:

Provider Business Practice Location Address
First Line	:	190 E 7TH ST
Second Line	:	APT 416
City	:	NEW YORK
State	:	NY
Zip	:	10009-5975
Country	:	US
Telephone Number	:	617-519-9685
Fax Number	:

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

Provider Enumeration Date	:	05/02/2011
Last Update Date	:	05/02/2011

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