Healthcare Provider Details

I. General information

NPI: 1356069728
Provider Name (Legal Business Name): ELIZABETH GRACE MARKO BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 08/22/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11872 WESTLINE INDUSTRIAL DR STE 100
SAINT LOUIS MO
63146-3331
US

IV. Provider business mailing address

11872 WESTLINE INDUSTRIAL DR STE 100
SAINT LOUIS MO
63146-3331
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-7944
  • Fax: 314-899-8666
Mailing address:
  • Phone: 314-991-7944
  • Fax: 314-899-8666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-61032
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: