Provider Demographics
NPI:1134614068
Name:RAYNOR, AUDREY NICOLE (BCBA)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:NICOLE
Last Name:RAYNOR
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-1648
Mailing Address - Country:US
Mailing Address - Phone:210-993-0212
Mailing Address - Fax:
Practice Address - Street 1:5009 CASCADE POOLS AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89131-3626
Practice Address - Country:US
Practice Address - Phone:210-993-0212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-23
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5249103K00000X
1-22-60738103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst