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General NPI Number Information
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NPI Number | 1891563771
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Entity Type | Organization
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Legal Business Name | EVENING STAR HOLISTIC & BEHAVIORAL SERVICES LLC
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Dates
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Enumeration Date | 12/19/2023
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Last Update Date | 12/29/2023
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Provider Practice Location Address
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Address Line | 2405 ESSINGTON RD STE B539
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City | JOLIET
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State | IL
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Zip | 60435-1200
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Country | US
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Telephone | 708-691-6249
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Fax |
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Provider Business Mailing Address
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Address Line | 2405 ESSINGTON RD STE B539
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City | JOLIET
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State | IL
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Zip | 60435-1200
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | REGISTERED AGENT
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Name | BRIAN GALL
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Credential | BCBA, AWC, RYT
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Telephone | 708-691-6249
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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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