Healthcare Provider Details

I. General information

NPI: 1770879421
Provider Name (Legal Business Name): GREEN, MAXVILLE, AND ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 06/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2743 RUSSELL BLVD
SAINT LOUIS MO
63104-2137
US

IV. Provider business mailing address

2743 RUSSELL BLVD
SAINT LOUIS MO
63104-2137
US

V. Phone/Fax

Practice location:
  • Phone: 573-864-9743
  • Fax:
Mailing address:
  • Phone: 573-864-9743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. DALE ALLEN MAXVILLE JR.
Title or Position: OWNER
Credential: PHD BCBA-D
Phone: 573-864-9743