Healthcare Provider Details

I. General information

NPI: 1902290232
Provider Name (Legal Business Name): SYNERGY ABA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2015
Last Update Date: 12/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7542 TRENTON AVE
SAINT LOUIS MO
63130-1316
US

IV. Provider business mailing address

7542 TRENTON AVE
SAINT LOUIS MO
63130-1316
US

V. Phone/Fax

Practice location:
  • Phone: 314-254-3591
  • Fax:
Mailing address:
  • Phone: 314-254-3591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2014011930
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number2014011930
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number2014011930
License Number StateMO

VIII. Authorized Official

Name: MR. BRANDON MAY
Title or Position: PRESIDENT
Credential: BCBA, LBA
Phone: 314-254-3591