Provider Demographics
NPI:1023375045
Name:BLYTH, ALICE MARIE (MA, LPC, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:MARIE
Last Name:BLYTH
Suffix:
Gender:F
Credentials:MA, LPC, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3403 N BELTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:MO
Mailing Address - Zip Code:64150-9502
Mailing Address - Country:US
Mailing Address - Phone:816-863-4542
Mailing Address - Fax:
Practice Address - Street 1:3403 N BELTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:MO
Practice Address - Zip Code:64150-9502
Practice Address - Country:US
Practice Address - Phone:816-863-4542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-15
Last Update Date:2012-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010007552101YP2500X
MO2012010600103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional