Healthcare Provider Details

I. General information

NPI: 1548772288
Provider Name (Legal Business Name): NANNAPAT MEETAM BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2017
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 185TH ST STE AB
TINLEY PARK IL
60487-9232
US

IV. Provider business mailing address

8421 STRATFORD DR
TINLEY PARK IL
60487-2119
US

V. Phone/Fax

Practice location:
  • Phone: 708-580-0440
  • Fax:
Mailing address:
  • Phone: 708-655-4252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-41175
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: