MEDICARE: DR. DALE ALLEN MAXVILLE JR. PHD BCBA-D

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	103K00000X	Behavior Analyst		MO

General Provider Information

NPI Number	:	1336209311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DALE ALLEN MAXVILLE JR. PHD BCBA-D

Provider Business Mailing Address
First Line	:	2743 RUSSELL BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-2137
Country	:	US
Telephone Number	:	573-864-9743
Fax Number	:	573-874-1723

Provider Business Practice Location Address
First Line	:	2743 RUSSELL BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-2137
Country	:	US
Telephone Number	:	573-864-9743
Fax Number	:	573-874-1723

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

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	06/21/2011

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