MEDICARE: MS. JANICE MARIE PELLECCHIA BCBA

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	1-03-1395	IL
2	103TB0200X	Cognitive & Behavioral Psychologist	1-03-1395	IL
3	103TM1800X	Intellectual & Developmental Disabilities Psychologist	1-03-1395	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1-03-1395	OTHER	FL	BEHAVIOR ANALYSIS CERTIFICATION BOARD (NATIONAL CERTIFICATION)

General Provider Information

NPI Number	:	1407069941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JANICE MARIE PELLECCHIA BCBA

Provider Business Mailing Address
First Line	:	1530 S STATE ST
Second Line	:	15Q
City	:	CHICAGO
State	:	IL
Zip	:	60605-2964
Country	:	US
Telephone Number	:	630-673-1211
Fax Number	:

Provider Business Practice Location Address
First Line	:	1530 S. STATE ST.
Second Line	:	15Q
City	:	CHICAGO
State	:	IL
Zip	:	60605-9954
Country	:	US
Telephone Number	:	630-673-1211
Fax Number	:

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

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	09/25/2013

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