Healthcare Provider Details

I. General information

NPI: 1023586096
Provider Name (Legal Business Name): BRIANNA RENEE CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date: 07/26/2023
Reactivation Date: 08/31/2023

III. Provider practice location address

575 BUSSE HWY UNIT C
PARK RIDGE IL
60068-3189
US

IV. Provider business mailing address

575 BUSSE HWY UNIT C
PARK RIDGE IL
60068-3189
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-63837
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: