Healthcare Provider Details

I. General information

NPI: 1629025044
Provider Name (Legal Business Name): RAE BARDELL BCBA, LCSWM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 W PRAIRIE DR STE G
SYCAMORE IL
60178-3123
US

IV. Provider business mailing address

206 S STANTON ST
SHANNON IL
61078-9311
US

V. Phone/Fax

Practice location:
  • Phone: 815-291-3887
  • Fax:
Mailing address:
  • Phone: 815-291-3887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.014536
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number152001169
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-18-30939
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: