Basic Information
| Provider Information | |||||||||
| NPI: | 1053808154 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLTER | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2104 LEWIS TURNER BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325471316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508623728 | ||||||||
| FaxNumber: | 8508626270 | ||||||||
| Practice Location | |||||||||
| Address1: | 419 RACETRACK RD NW | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325474612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508642273 | ||||||||
| FaxNumber: | 8508626270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2018 | ||||||||
| LastUpdateDate: | 04/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-17-28898 | FL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.