Healthcare Provider Details

I. General information

NPI: 1790193696
Provider Name (Legal Business Name): NICOLE BUENEMANN MA, BCBA, LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE TIESING

II. Dates (important events)

Enumeration Date: 07/24/2014
Last Update Date: 07/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 BERNADETTE DR
COLUMBIA MO
65203-5007
US

IV. Provider business mailing address

918 BERNADETTE DR
COLUMBIA MO
65203-5007
US

V. Phone/Fax

Practice location:
  • Phone: 573-447-8318
  • Fax: 573-874-3777
Mailing address:
  • Phone: 573-447-8318
  • Fax: 573-874-3777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2014025303
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: