Provider Demographics
NPI:1760967707
Name:LIGHT, SIMONE LILA (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:LILA
Last Name:LIGHT
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4721 S. CLIFF AVE SUITE 103
Mailing Address - Street 2:SUITE 103
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055
Mailing Address - Country:US
Mailing Address - Phone:816-368-8120
Mailing Address - Fax:800-687-5070
Practice Address - Street 1:4721 S. CLIFF AVE SUITE 103
Practice Address - Street 2:SUITE 103
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055
Practice Address - Country:US
Practice Address - Phone:816-368-8120
Practice Address - Fax:800-687-5070
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRBT-18-62827106S00000X
OH1-20-43267103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician