MEDICARE: CALEB RYAN STANLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-17-24990	IL

General Provider Information

NPI Number	:	1336625508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CALEB RYAN STANLEY

Provider Business Mailing Address
First Line	:	4294 BOSKYDELL RD
Second Line	:
City	:	CARBONDALE
State	:	IL
Zip	:	62903-7611
Country	:	US
Telephone Number	:	662-882-8116
Fax Number	:

Provider Business Practice Location Address
First Line	:	4114 N WATER TOWER PL STE C
Second Line	:
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-6548
Country	:	US
Telephone Number	:	662-882-8116
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2018
Last Update Date	:	07/11/2018

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