Healthcare Provider Details

I. General information

NPI: 1396227070
Provider Name (Legal Business Name): BEHAVIORAL SERVICES FOR AUTISM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2018
Last Update Date: 04/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1095 PINGREE ROAD SUITE 204
CRYSTAL LAKE IL
60014
US

IV. Provider business mailing address

1095 PINGREE ROAD SUITE 204
CRYSTAL LAKE IL
60014
US

V. Phone/Fax

Practice location:
  • Phone: 815-277-9505
  • Fax:
Mailing address:
  • Phone: 815-277-9505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: MR. BARRINGTON LAWRENCE JR.
Title or Position: PRESIDENT
Credential: REGISTERED BEHAVIOR
Phone: 815-277-9505