Healthcare Provider Details

I. General information

NPI: 1225637374
Provider Name (Legal Business Name): IGOR LUIZ MACIEL BURSTEIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: IGOR LUIZ MACIEL

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6414 W NORTH AVE
CHICAGO IL
60707
US

IV. Provider business mailing address

1919 S MICHIGAN AVE UNIT 411
CHICAGO IL
60616-1690
US

V. Phone/Fax

Practice location:
  • Phone: 708-787-8840
  • Fax:
Mailing address:
  • Phone: 954-851-4741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: