Provider Demographics
NPI:1255537338
Name:THE SHAPE OF BEHAVIOR
Entity type:Organization
Organization Name:THE SHAPE OF BEHAVIOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DOMONIQUE
Authorized Official - Middle Name:Y
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:MS BCBA
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:832-359-3530
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:832-359-3530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-00-0350174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty