MEDICARE: SPROUT BEHAVIOR AND SKILLS THERAPY LLC

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	106S00000X	Behavior Technician
2	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1316760713
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPROUT BEHAVIOR AND SKILLS THERAPY LLC

Provider Business Mailing Address
First Line	:	5717 NW 115TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-3545
Country	:	US
Telephone Number	:	405-887-5719
Fax Number	:

Provider Business Practice Location Address
First Line	:	5717 NW 115TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-3545
Country	:	US
Telephone Number	:	405-887-5719
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. REISHA DESPAIN
Credential	:	BCBA
Telephone Number	:	405-887-5719

Provider Enumeration Date	:	11/04/2024
Last Update Date	:	11/04/2024

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