Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103K00000X | Behavior Analyst | RBT-19-104282 | MO |
NPI | 1003440728 |
---|---|
Provider Name | Kacey Russell |
First Address | Olivette, MO 63132-3253 |
Second Address | Olivette, MO 63132-3253 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/03/2020 |
Last Update Date | 03/03/2020 |