Healthcare Provider Details

I. General information

NPI: 1043966526
Provider Name (Legal Business Name): ELIJAH MICHAEL AUGUSTINE MS, PLBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2022
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 NE WINDSOR DR
LEES SUMMIT MO
64086-5594
US

IV. Provider business mailing address

1220 NE WINDSOR DR
LEES SUMMIT MO
64086-5594
US

V. Phone/Fax

Practice location:
  • Phone: 573-410-8176
  • Fax:
Mailing address:
  • Phone: 573-410-8176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2026011574
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: