Healthcare Provider Details

I. General information

NPI: 1013837772
Provider Name (Legal Business Name): TARA CANNELLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ESSINGTON RD
JOLIET IL
60435-2841
US

IV. Provider business mailing address

115 TERRY ELLEN LN
NEW LENOX IL
60451-1143
US

V. Phone/Fax

Practice location:
  • Phone: 815-293-7333
  • Fax:
Mailing address:
  • Phone: 815-585-0193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: