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General NPI Number Information
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NPI Number | 1740522549
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Entity Type | Organization
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Legal Business Name | IMPACTING AUTISM, LLC
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Dates
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Enumeration Date | 03/20/2013
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Last Update Date | 07/02/2016
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Provider Practice Location Address
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Address Line | 1613 W COLONIAL PKWY SUITE 200
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City | INVERNESS
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State | IL
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Zip | 60067-4827
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Country | US
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Telephone | 847-331-5370
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Fax | 847-202-1150
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Provider Business Mailing Address
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Address Line | 1613 W COLONIAL PKWY SUITE 200
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City | INVERNESS
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State | IL
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Zip | 60067-4827
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Country | US
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Telephone | 847-331-5370
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Fax | 847-202-1150
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Authorized Official
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Title or Position | BOARD CERTIFIED BEHAVIOR ANALYST
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Name | DIANNA POULOS
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Credential | M.A.,BCBA
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Telephone | 847-331-5370
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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 | 1-09-6494
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License Number State | IL
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