Healthcare Provider Details

I. General information

NPI: 1760742191
Provider Name (Legal Business Name): ALLIA OGDEN BCABA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2012
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 W AINSLIE ST
CHICAGO IL
60625-6155
US

IV. Provider business mailing address

3915 W AINSLIE ST APT 2
CHICAGO IL
60625-6155
US

V. Phone/Fax

Practice location:
  • Phone: 312-823-5912
  • Fax:
Mailing address:
  • Phone: 312-823-5912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-19-10242
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: