Healthcare Provider Details

I. General information

NPI: 1427699032
Provider Name (Legal Business Name): INTERIOR BEHAVIOR CONSULTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2019
Last Update Date: 11/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3095 PEWTER CT
NORTH POLE AK
99705-7594
US

IV. Provider business mailing address

3095 PEWTER CT
NORTH POLE AK
99705-7594
US

V. Phone/Fax

Practice location:
  • Phone: 618-381-3033
  • Fax:
Mailing address:
  • Phone: 618-381-3033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE ROE
Title or Position: BEHAVIOR ANALYST
Credential: BCBA
Phone: 618-381-3033