MEDICARE: CHICAGO BEHAVIOR & LEARNING GROUP INC.

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	1-10-7620	IL

General Provider Information

NPI Number	:	1205219136
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO BEHAVIOR & LEARNING GROUP INC.

Provider Business Mailing Address
First Line	:	1737 N WILMOT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5523
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1737 N WILMOT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-5523
Country	:	US
Telephone Number	:	757-660-9320
Fax Number	:

Authorized Official
Title or Position	:	BCBA/PRESIDENT
Name	:	NICOLE JANSMA
Credential	:	M.S., BCBA
Telephone Number	:	757-660-9320

Provider Enumeration Date	:	07/09/2015
Last Update Date	:	03/28/2016

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