Provider Demographics
NPI:1619748266
Name:STAILEY, AENEAS (RBT)
Entity Type:Individual
Prefix:
First Name:AENEAS
Middle Name:
Last Name:STAILEY
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 S WILSON ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-5841
Mailing Address - Country:US
Mailing Address - Phone:575-740-8481
Mailing Address - Fax:
Practice Address - Street 1:1115 S WILSON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-5841
Practice Address - Country:US
Practice Address - Phone:505-313-6415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician