Provider Demographics
NPI:1891162111
Name:THE SHAPE OF BEHAVIOR, INC
Entity Type:Organization
Organization Name:THE SHAPE OF BEHAVIOR, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMONIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:832-358-2655
Mailing Address - Street 1:12941 NORTH FWY
Mailing Address - Street 2:STE 750
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77060-1240
Mailing Address - Country:US
Mailing Address - Phone:832-358-2655
Mailing Address - Fax:832-358-3530
Practice Address - Street 1:12941 NORTH FWY
Practice Address - Street 2:STE 750
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77060-1240
Practice Address - Country:US
Practice Address - Phone:832-358-2655
Practice Address - Fax:832-358-3530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty