Healthcare Provider Details

I. General information

NPI: 1972172526
Provider Name (Legal Business Name): CASSIDY ANCIRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 PARKVIEW BLVD
LOMBARD IL
60148-3200
US

IV. Provider business mailing address

4655 KIRCHOFF RD # 39
ROLLING MEADOWS IL
60008-2070
US

V. Phone/Fax

Practice location:
  • Phone: 630-449-3101
  • Fax:
Mailing address:
  • Phone: 847-323-5536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-60792
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: