Healthcare Provider Details

I. General information

NPI: 1790264927
Provider Name (Legal Business Name): INDEPENDENT WITH AUTISM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SAUNDERS RD STE 150
LAKE FOREST IL
60045-2526
US

IV. Provider business mailing address

2549 WAUKEGAN RD STE 55
BANNOCKBURN IL
60015-1569
US

V. Phone/Fax

Practice location:
  • Phone: 847-275-9413
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MS. SUSAN PERKOWITZ
Title or Position: OWNER
Credential:
Phone: 847-274-9413