Healthcare Provider Details

I. General information

NPI: 1689578981
Provider Name (Legal Business Name): PAVEL IVANCHENKO RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N GREENLEAF ST STE B
GURNEE IL
60031-3326
US

IV. Provider business mailing address

2086 SAINT JOHNS AVE APT 207
HIGHLAND PARK IL
60035-2461
US

V. Phone/Fax

Practice location:
  • Phone: 630-465-3963
  • Fax:
Mailing address:
  • Phone: 484-688-4226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: