Provider Demographics
NPI:1598327595
Name:SOUTHEAST BEHAVIOR INTERVENTION & CONSULTATION
Entity Type:Organization
Organization Name:SOUTHEAST BEHAVIOR INTERVENTION & CONSULTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT BEHAVIOR ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:BRAZER
Authorized Official - Suffix:
Authorized Official - Credentials:BCABA, LABA
Authorized Official - Phone:573-225-5828
Mailing Address - Street 1:373 RYLANE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-8730
Mailing Address - Country:US
Mailing Address - Phone:573-225-5828
Mailing Address - Fax:
Practice Address - Street 1:373 RYLANE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-8730
Practice Address - Country:US
Practice Address - Phone:573-225-5828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-01
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO730026462Medicaid