Provider Demographics
NPI:1548557259
Name:DOUGLAS, BECKY LEE (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:BECKY
Middle Name:LEE
Last Name:DOUGLAS
Suffix:
Gender:F
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:PO BOX 394
Mailing Address - Street 2:
Mailing Address - City:QUEEN CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63561-0394
Mailing Address - Country:US
Mailing Address - Phone:660-216-4709
Mailing Address - Fax:
Practice Address - Street 1:1101 OLIVE STREET
Practice Address - Street 2:
Practice Address - City:QUEEN CITY
Practice Address - State:MO
Practice Address - Zip Code:63561
Practice Address - Country:US
Practice Address - Phone:660-216-4709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011014803320900000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities