Healthcare Provider Details

I. General information

NPI: 1619426806
Provider Name (Legal Business Name): ROBERT CORMIER PHD, BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2016
Last Update Date: 01/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 FRANCIS PL
SAINT LOUIS MO
63105-2462
US

IV. Provider business mailing address

716 FRANCIS PL
SAINT LOUIS MO
63105-2462
US

V. Phone/Fax

Practice location:
  • Phone: 314-632-6206
  • Fax: 314-658-9374
Mailing address:
  • Phone: 314-632-6206
  • Fax: 314-658-9374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2016035860
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: