Healthcare Provider Details

I. General information

NPI: 1912408022
Provider Name (Legal Business Name): CARISSA COLLADO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2018
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2011 S WASHINGTON ST
NAPERVILLE IL
60565-1368
US

IV. Provider business mailing address

2011 S WASHINGTON ST
NAPERVILLE IL
60565-1368
US

V. Phone/Fax

Practice location:
  • Phone: 815-469-1500
  • Fax: 779-216-3069
Mailing address:
  • Phone: 815-469-1500
  • Fax: 779-216-3069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-39492
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: