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General NPI Number Information
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NPI Number | 1467058404
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Entity Type | Organization
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Legal Business Name | CULTIVATE BEHAVIORAL HEALTH AND EDUCATION- ILLINOIS
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Dates
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Enumeration Date | 12/06/2020
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Last Update Date | 12/06/2020
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Provider Practice Location Address
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Address Line | 11055 S NAGLE AVE APT 5
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City | WORTH
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State | IL
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Zip | 60482-1655
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Country | US
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Telephone | 224-703-0502
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Fax |
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Provider Business Mailing Address
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Address Line | 11055 S NAGLE AVE APT 5
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City | WORTH
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State | IL
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Zip | 60482-1655
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Country | US
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Telephone | 224-703-0502
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Fax |
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Authorized Official
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Title or Position | REGIONAL VICE PRESIDENT
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Name | OZZIE HOLMGREN
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Credential | M.ED., BCBA
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Telephone | 631-804-4268
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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