Healthcare Provider Details

I. General information

NPI: 1760977342
Provider Name (Legal Business Name): MIRANDA RENEE ILLIUS BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2018
Last Update Date: 11/21/2022
Certification Date: 11/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38530 CHESTER RD STE 100
AVON OH
44011-4048
US

IV. Provider business mailing address

27991 CENTER RIDGE RD
WESTLAKE OH
44145-3902
US

V. Phone/Fax

Practice location:
  • Phone: 216-282-1234
  • Fax:
Mailing address:
  • Phone: 440-455-3230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-18-30479
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: