Provider Demographics
NPI:1225530439
Name:LOVELACE, BRYAN SCOTT (BCBA)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:SCOTT
Last Name:LOVELACE
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 DREAM CATCHER WAY
Mailing Address - Street 2:
Mailing Address - City:KRUM
Mailing Address - State:TX
Mailing Address - Zip Code:76249-7558
Mailing Address - Country:US
Mailing Address - Phone:940-536-3211
Mailing Address - Fax:
Practice Address - Street 1:1619 DREAM CATCHER WAY
Practice Address - Street 2:
Practice Address - City:KRUM
Practice Address - State:TX
Practice Address - Zip Code:76249-7558
Practice Address - Country:US
Practice Address - Phone:940-536-3211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-03
Last Update Date:2018-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-09-5043103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1871095323OtherTEXAS BEHAVIOR SERVICES LLC