Healthcare Provider Details

I. General information

NPI: 1487150702
Provider Name (Legal Business Name): RICHARD WAWRZONKOWSKI BCABA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 N RIVER LN STE 2109
GENEVA IL
60134-2003
US

IV. Provider business mailing address

937 NORTHWAY CT
HANOVER PARK IL
60133-2648
US

V. Phone/Fax

Practice location:
  • Phone: 331-222-7724
  • Fax: 844-447-0582
Mailing address:
  • Phone: 224-830-0515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: