Healthcare Provider Details

I. General information

NPI: 1013307776
Provider Name (Legal Business Name): ANNETTE GRANDOLFO BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2015
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

452 N EOLA RD
AURORA IL
60502
US

IV. Provider business mailing address

452 N EOLA RD
AURORA IL
60502-9612
US

V. Phone/Fax

Practice location:
  • Phone: 888-308-3728
  • Fax:
Mailing address:
  • Phone: 888-308-3728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-14-17577
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: