Healthcare Provider Details

I. General information

NPI: 1013677038
Provider Name (Legal Business Name): TRACY LYNETTE BROWN BEHAVIOR SUPPORT TEC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2021
Last Update Date: 12/20/2021
Certification Date: 12/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3863 CLEVELAND AVE
SAINT LOUIS MO
63110-4009
US

IV. Provider business mailing address

3863 CLEVELAND AVE
SAINT LOUIS MO
63110-4009
US

V. Phone/Fax

Practice location:
  • Phone: 314-664-3927
  • Fax: 314-664-0556
Mailing address:
  • Phone: 314-664-3927
  • Fax: 314-664-0556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: