Basic Information
| Provider Information | |||||||||
| NPI: | 1689172165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORNEAU | ||||||||
| FirstName: | TAMMY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MA, BCBA, COBA, LBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 DEPAUW BLVD STE 3070 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462686135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553240885 | ||||||||
| FaxNumber: | 7654549759 | ||||||||
| Practice Location | |||||||||
| Address1: | 7264 COLUMBIA RD STE 1000 | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134021711 | ||||||||
| FaxNumber: | 7654549759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2018 | ||||||||
| LastUpdateDate: | 06/05/2018 | ||||||||
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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 | 241585 | KY | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | COBA.00400 | OH | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | COBA.00400 | 01 | OH | COBA LICENSE | OTHER | 1-08-4205 | 01 | BCBA CERTIFICATE | OTHER |