Healthcare Provider Details

I. General information

NPI: 1487266805
Provider Name (Legal Business Name): MEGAN C GILDERSLEEVE BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2020
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1136 S DELANO CT W STE B201
CHICAGO IL
60605-3734
US

IV. Provider business mailing address

5451 BUCKEYE AVE
PORTAGE IN
46368-4205
US

V. Phone/Fax

Practice location:
  • Phone: 219-921-5747
  • Fax:
Mailing address:
  • Phone: 219-921-5747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-58165
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-16-20966
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: