Healthcare Provider Details

I. General information

NPI: 1205303849
Provider Name (Legal Business Name): BRENDEN TYLER PHELPS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2018
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2990 N PERRYVILLE RD UNIT 1100
ROCKFORD IL
61107-6827
US

IV. Provider business mailing address

9500 BORMET DR STE 304
MOKENA IL
60448-8399
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 Number152.003783
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: