Healthcare Provider Details

I. General information

NPI: 1588074116
Provider Name (Legal Business Name): MORNING STAR BEHAVIORAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2014
Last Update Date: 08/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 QUAIL CRK
JACKSON MO
63755-3810
US

IV. Provider business mailing address

219 QUAIL CRK
JACKSON MO
63755-3810
US

V. Phone/Fax

Practice location:
  • Phone: 618-697-1132
  • Fax:
Mailing address:
  • Phone: 618-697-1132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2013009325
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. LINDSEY MICHELLE RADCLIFFE
Title or Position: PARTNER
Credential: QIDP, DDP
Phone: 618-697-1132