Healthcare Provider Details

I. General information

NPI: 1730095431
Provider Name (Legal Business Name): DYANA NICANOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N ADDISON AVE
ELMHURST IL
60126-2809
US

IV. Provider business mailing address

1522 N 19TH AVE APT 1
MELROSE PARK IL
60160-2031
US

V. Phone/Fax

Practice location:
  • Phone: 866-673-5278
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-2842377
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: