Provider Demographics
NPI:1508474602
Name:VANTIC, SANDRA (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:VANTIC
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7522 BIG BEND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-2104
Mailing Address - Country:US
Mailing Address - Phone:573-424-2948
Mailing Address - Fax:573-874-1723
Practice Address - Street 1:7522 BIG BEND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-2104
Practice Address - Country:US
Practice Address - Phone:573-424-2948
Practice Address - Fax:573-874-1723
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017030311103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst