=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669211173
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MYA NICOLE ST LOUIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2024
-----------------------------------------------------
Last Update Date | 05/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 170 N 15TH ST
-----------------------------------------------------
City | EAST ORANGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07017-5271
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-576-4968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7108 S KANNER HWY
-----------------------------------------------------
City | STUART
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34997-7462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-567-4986
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106E00000X
-----------------------------------------------------
Taxonomy Name | Assistant Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------