MEDICARE: ALICE MARIE BLYTH MA, LPC, BCBA, LBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	2010007552	MO
2	103K00000X	Behavior Analyst	2012010600	MO

General Provider Information

NPI Number	:	1023375045
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICE MARIE BLYTH MA, LPC, BCBA, LBA

Provider Business Mailing Address
First Line	:	3403 N BELTON AVE
Second Line	:
City	:	RIVERSIDE
State	:	MO
Zip	:	64150-9502
Country	:	US
Telephone Number	:	816-863-4542
Fax Number	:

Provider Business Practice Location Address
First Line	:	3403 N BELTON AVE
Second Line	:
City	:	RIVERSIDE
State	:	MO
Zip	:	64150-9502
Country	:	US
Telephone Number	:	816-863-4542
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2012
Last Update Date	:	04/15/2012

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