Healthcare Provider Details

I. General information

NPI: 1013661990
Provider Name (Legal Business Name): ELIZABETH JEANETTE ALTMAN BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2022
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 N SHEFFIELD AVE
CHICAGO IL
60614-3936
US

IV. Provider business mailing address

625 W DIVISION ST UNIT 911
CHICAGO IL
60610-2597
US

V. Phone/Fax

Practice location:
  • Phone: 773-389-2202
  • Fax:
Mailing address:
  • Phone: 314-825-0255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-55259
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: