Healthcare Provider Details

I. General information

NPI: 1720329865
Provider Name (Legal Business Name): BEHAVIOR THERAPY SPECIALISTS OF IL AND MO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2013
Last Update Date: 03/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 W SARAH AVE
SAINT LOUIS MO
63122-2646
US

IV. Provider business mailing address

126 W SARAH AVE
SAINT LOUIS MO
63122-2646
US

V. Phone/Fax

Practice location:
  • Phone: 314-252-2069
  • Fax: 314-698-2570
Mailing address:
  • Phone: 314-252-2069
  • Fax: 314-698-2570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number111880
License Number StateMO

VIII. Authorized Official

Name: JENNA DEE CUENCA
Title or Position: BEHAVIOR ANALYST/OWNER
Credential: BCBA
Phone: 314-252-2069