Healthcare Provider Details

I. General information

NPI: 1265067813
Provider Name (Legal Business Name): ELMA BUMBULOVIC RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9374 OLIVE BLVD STE 101
OLIVETTE MO
63132-3253
US

IV. Provider business mailing address

9374 OLIVE BLVD STE 101
OLIVETTE MO
63132-3253
US

V. Phone/Fax

Practice location:
  • Phone: 314-932-2402
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberRBT-19-101361
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: