Basic Information
| Provider Information | |||||||||
| NPI: | 1063000966 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOVERNAL | ||||||||
| FirstName: | LAUREL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12110 CLAYTON RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631312516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149898150 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12110 CLAYTON RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631312516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149898150 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2021 | ||||||||
| LastUpdateDate: | 01/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-18-32719 | MO | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | 2018041211 | MO | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.