MEDICARE: TARA GLAVIN MA, BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-08-4015

General Provider Information

NPI Number	:	1003214487
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA GLAVIN MA, BCBA

Provider Business Mailing Address
First Line	:	1420 W GRAND AVE
Second Line	:	UNIT 2
City	:	CHICAGO
State	:	IL
Zip	:	60642-8873
Country	:	US
Telephone Number	:	847-477-7729
Fax Number	:

Provider Business Practice Location Address
First Line	:	1420 W GRAND AVE
Second Line	:	UNIT 2
City	:	CHICAGO
State	:	IL
Zip	:	60642-8873
Country	:	US
Telephone Number	:	847-477-7729
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2014
Last Update Date	:	12/16/2014

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