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General NPI Number Information
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NPI Number | 1558818930
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Entity Type | Organization
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Legal Business Name | AUTISMCHICAGO
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Dates
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Enumeration Date | 09/02/2016
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Last Update Date | 09/02/2016
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Provider Practice Location Address
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Address Line | 8035 S WABASH AVE
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City | CHICAGO
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State | IL
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Zip | 60619-3516
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Country | US
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Telephone | 773-595-5168
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Fax |
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Provider Business Mailing Address
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Address Line | 8035 S WABASH AVE
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City | CHICAGO
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State | IL
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Zip | 60619-3516
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Country | US
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Telephone | 773-595-5168
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Fax |
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Authorized Official
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Title or Position | BAHAVIORAL HEALTH TECHNICIAN
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Name | TIFFANY COLE
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Credential | MBA, MAP, BCBA, RBT
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Telephone | 773-595-5168
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number | 103K00000X
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License Number State | IL
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