Healthcare Provider Details

I. General information

NPI: 1528550175
Provider Name (Legal Business Name): GIANNA ROSE SQUEO BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8609 W BRYN MAWR AVE STE 204
CHICAGO IL
60631-3524
US

IV. Provider business mailing address

5 REVERE DR STE 120
NORTHBROOK IL
60062-8005
US

V. Phone/Fax

Practice location:
  • Phone: 773-644-7787
  • Fax:
Mailing address:
  • Phone: 847-807-3717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-39940
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: