MEDICARE: MRS. BECKY LEE DOUGLAS BCBA

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	2011014803	MO
2	103K00000X	Behavior Analyst	2011014803	MO

General Provider Information

NPI Number	:	1548557259
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BECKY LEE DOUGLAS BCBA

Provider Business Mailing Address
First Line	:	PO BOX 394
Second Line	:
City	:	QUEEN CITY
State	:	MO
Zip	:	63561-0394
Country	:	US
Telephone Number	:	660-216-4709
Fax Number	:

Provider Business Practice Location Address
First Line	:	1101 OLIVE STREET
Second Line	:
City	:	QUEEN CITY
State	:	MO
Zip	:	63561
Country	:	US
Telephone Number	:	660-216-4709
Fax Number	:

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

Provider Enumeration Date	:	07/01/2011
Last Update Date	:	07/21/2011

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