Healthcare Provider Details

I. General information

NPI: 1730653049
Provider Name (Legal Business Name): ANGELICA GALLEGOS BCBA 1-21-48488
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2019
Last Update Date: 04/12/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

854 TECHNOLOGY WAY
LIBERTYVILLE IL
60048-5350
US

IV. Provider business mailing address

372 DORCHESTER LN
GRAYSLAKE IL
60030-3429
US

V. Phone/Fax

Practice location:
  • Phone: 847-816-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-48488
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-75290
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: