Healthcare Provider Details

I. General information

NPI: 1295691939
Provider Name (Legal Business Name): AUSTIN COOLBAUGH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2025
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 WASHINGTON AVE SUITE 229, ST. LOUIS, MO 63103
ST LOUIS MO
63103
US

IV. Provider business mailing address

2475 W MONROE ST
SPRINGFIELD IL
62704-1439
US

V. Phone/Fax

Practice location:
  • Phone: 314-970-5755
  • Fax:
Mailing address:
  • Phone: 217-843-0290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-460662
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: