=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346805181
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY JANE GLOVER BCBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2019
-----------------------------------------------------
Last Update Date | 07/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1305 S KEY AVE STE 207
-----------------------------------------------------
City | LAMPASAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76550-3580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-554-1466
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24852 STILLMAN VALLEY RD
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76527-4066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 4777
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------