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General NPI Number Information
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NPI Number | 1356611024
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Entity Type | Organization
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Legal Business Name | SHAWNEE BEHAVIORAL CONSULTATION LLC
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Dates
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Enumeration Date | 01/11/2012
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Last Update Date | 01/11/2012
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Provider Practice Location Address
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Address Line | 224 BELDEN DR
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City | EDWARDSVILLE
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State | IL
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Zip | 62025-3178
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Country | US
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Telephone | 618-977-2773
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Fax | 312-626-2429
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Provider Business Mailing Address
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Address Line | 7384 SHARP AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63116-3040
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Country | US
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Telephone | 618-977-2773
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Fax | 312-626-2429
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Authorized Official
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Title or Position | BOARD CERTIFIED BEHAVIOR ANALYST
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Name | CHRISTINA ANN RUZICKA
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Credential | M.S., BCBA
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Telephone | 618-977-2773
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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 | 1084838
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License Number State | IL
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