Provider Demographics
NPI:1649576646
Name:SMITH, JANICE MARIE (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 COPPER TREE CT
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-6339
Mailing Address - Country:US
Mailing Address - Phone:636-265-0407
Mailing Address - Fax:636-265-0407
Practice Address - Street 1:321 COPPER TREE CT
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-6339
Practice Address - Country:US
Practice Address - Phone:636-265-0407
Practice Address - Fax:636-265-0407
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010042660174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist