Healthcare Provider Details

I. General information

NPI: 1336209311
Provider Name (Legal Business Name): DALE ALLEN MAXVILLE JR. PHD BCBA-D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
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: 573-874-1723
Mailing address:
  • Phone: 573-864-9743
  • Fax: 573-874-1723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: