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Individual provider Active NPI Behavior Technician · Burnsville, MN

NPI 1417740424 · NPPES record last updated May 23, 2025

Key facts

NPI
1417740424
Entity type
Individual (NPI type 1)
Primary specialty
Behavior Technician 106S00000X
Practice address
11972 Portland Ave
Burnsville, MN 55337-1516
Phone
(952) 658-8670
NPI assigned
May 23, 2025
Sex
Male
Sole proprietor
Yes

Medicare participation

Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD)
No

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Behavior Technician 106S00000X Yes

Addresses

Primary practice location

11972 Portland Ave
Burnsville, MN 55337-1516

Mailing address

11972 Portland Ave
Burnsville, MN 55337-1516
Phone (952) 658-8670

Other providers in Burnsville, MN

All providers in Burnsville, MN · Behavior Technician in Minnesota

Sources for this page

Verify at the official NPI Registry.