Healthcare Provider Details

I. General information

NPI: 1083212740
Provider Name (Legal Business Name): GILLIAN BEDNAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 COMMERCIAL CT STE C
VENICE FL
34292-1655
US

IV. Provider business mailing address

5 REVERE DR STE 120
NORTHBROOK IL
60062-8005
US

V. Phone/Fax

Practice location:
  • Phone: 800-356-4049
  • Fax: 941-485-0519
Mailing address:
  • Phone: 800-356-4049
  • Fax: 941-485-0519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-139659
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: