Healthcare Provider Details

I. General information

NPI: 1396234894
Provider Name (Legal Business Name): CARISSA SHOULTZ RBT-17-38260
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2018
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2602 N SAINT LOUIS AVE # 3
CHICAGO IL
60647-1216
US

IV. Provider business mailing address

2602 N SAINT LOUIS AVE # 3
CHICAGO IL
60647-1216
US

V. Phone/Fax

Practice location:
  • Phone: 608-345-2474
  • Fax:
Mailing address:
  • Phone: 608-345-2474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-49774
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number17-38260
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: