Healthcare Provider Details

I. General information

NPI: 1578072666
Provider Name (Legal Business Name): DIANA L CLIFFORD BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2017
Last Update Date: 09/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 N EAST ST
GARDNER IL
60424
US

IV. Provider business mailing address

317 N EAST ST
GARDNER IL
60424-7024
US

V. Phone/Fax

Practice location:
  • Phone: 815-584-7380
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: