=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942454681
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN PINGO BCBA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2008
-----------------------------------------------------
Last Update Date | 03/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 58 W ROCKTON RD
-----------------------------------------------------
City | ROCKTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61072-1631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-624-8431
-----------------------------------------------------
Fax | 815-624-8461
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4596 SADDLE ST
-----------------------------------------------------
City | LOVES PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61111-5335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-985-8465
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------