Healthcare Provider Details

I. General information

NPI: 1144906223
Provider Name (Legal Business Name): AUTISM BEHAVIOR THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2023
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4954 W 95TH ST
OAK LAWN IL
60453-2504
US

IV. Provider business mailing address

44 W ROOSEVELT RD
LOMBARD IL
60148-4402
US

V. Phone/Fax

Practice location:
  • Phone: 855-528-8476
  • Fax:
Mailing address:
  • Phone: 855-528-8476
  • Fax: 630-687-8737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: SHADEN KASSAR
Title or Position: BCBA
Credential:
Phone: 630-631-9623