Healthcare Provider Details

I. General information

NPI: 1487150702
Provider Name (Legal Business Name): RICHARD WAWRZONKOWSKI MS, BCBA, LBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2255 ENTERPRISE DR STE 5501
WESTCHESTER IL
60154-5808
US

IV. Provider business mailing address

937 NORTHWAY CT
HANOVER PARK IL
60133-2648
US

V. Phone/Fax

Practice location:
  • Phone: 708-965-4123
  • Fax:
Mailing address:
  • Phone: 224-830-0515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number152002628
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: