Healthcare Provider Details

I. General information

NPI: 1033038898
Provider Name (Legal Business Name): ETHAN WEISS RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4908 N ELSTON AVE
CHICAGO IL
60630-2506
US

IV. Provider business mailing address

2901 FINLEY RD STE 102
DOWNERS GROVE IL
60515-1774
US

V. Phone/Fax

Practice location:
  • Phone: 317-520-4748
  • Fax:
Mailing address:
  • Phone: 317-520-4748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-495427
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: