Provider Demographics
NPI:1932560513
Name:ERVIN, THEA RAE (MS ABA, BCBA, LBA)
Entity Type:Individual
Prefix:MS
First Name:THEA
Middle Name:RAE
Last Name:ERVIN
Suffix:
Gender:F
Credentials:MS ABA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 N 23RD ST APT 513
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63103-1547
Mailing Address - Country:US
Mailing Address - Phone:270-997-1470
Mailing Address - Fax:
Practice Address - Street 1:12400 OLIVE BLVD STE 340
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-5456
Practice Address - Country:US
Practice Address - Phone:314-750-0068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016003795103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst