Healthcare Provider Details

I. General information

NPI: 1245922954
Provider Name (Legal Business Name): AUTISM BEHAVIOR THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4830 N PULASKI RD STE 110
CHICAGO IL
60630-2846
US

IV. Provider business mailing address

124 KRAML DR
BURR RIDGE IL
60527-0303
US

V. Phone/Fax

Practice location:
  • Phone: 855-528-8476
  • Fax: 630-687-8737
Mailing address:
  • Phone: 630-631-9623
  • Fax: 630-290-0522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: ANTONELA CIUPE
Title or Position: DIRECTOR
Credential: PHD
Phone: 773-306-6239