Healthcare Provider Details

I. General information

NPI: 1073966719
Provider Name (Legal Business Name): FOREST CITY BEHAVIOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2016
Last Update Date: 07/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 MONROE ST
MENDOTA IL
61342-1662
US

IV. Provider business mailing address

807 MONROE ST
MENDOTA IL
61342-1662
US

V. Phone/Fax

Practice location:
  • Phone: 815-627-0641
  • Fax: 270-514-8294
Mailing address:
  • Phone: 815-627-0641
  • Fax: 270-514-8294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number071-007297
License Number StateIL

VIII. Authorized Official

Name: DR. ERIN WADE
Title or Position: PRESIDENT
Credential: PHD
Phone: 815-627-0641