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General NPI Number Information
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NPI Number | 1336526979
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Entity Type | Organization
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Legal Business Name | POWDER RIVER BEHAVIOR CONSULTATION, LLC
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Dates
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Enumeration Date | 05/04/2015
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Last Update Date | 05/04/2015
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Provider Practice Location Address
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Address Line | 812 GLACIER ST
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City | GILLETTE
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State | WY
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Zip | 82718-5752
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Country | US
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Telephone | 949-922-3043
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Fax |
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Provider Business Mailing Address
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Address Line | 812 GLACIER ST
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City | GILLETTE
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State | WY
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Zip | 82718-5752
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Country | US
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Telephone | 949-922-3043
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. KRISTINA MARIE LESLIE
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Credential | LMFT, BCBA
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Telephone | 949-922-3043
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1-13-13894
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License Number State | CO
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