Provider Demographics
NPI:1043886393
Name:HOLTGREVEN, MARISA (MA, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:HOLTGREVEN
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 RUE SAINT FRANCOIS ST
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-4905
Mailing Address - Country:US
Mailing Address - Phone:314-377-3274
Mailing Address - Fax:870-641-7171
Practice Address - Street 1:1720 W ELFINDALE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-1289
Practice Address - Country:US
Practice Address - Phone:417-494-3274
Practice Address - Fax:870-641-7171
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021029719103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst