MEDICARE: DYANNA ISHTAR PACHECO RBT-17-31942

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	106S00000X	Behavior Technician	17-31942	IL

General Provider Information

NPI Number	:	1467689364
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DYANNA ISHTAR PACHECO RBT-17-31942

Provider Business Mailing Address
First Line	:	12 W PEBBLE BEACH CIR APT 301
Second Line	:
City	:	GLENDALE HEIGHTS
State	:	IL
Zip	:	60139-3625
Country	:	US
Telephone Number	:	312-961-2567
Fax Number	:

Provider Business Practice Location Address
First Line	:	12 W PEBBLE BEACH CIR APT 301
Second Line	:
City	:	GLENDALE HEIGHTS
State	:	IL
Zip	:	60139-3625
Country	:	US
Telephone Number	:	312-961-2567
Fax Number	:

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

Provider Enumeration Date	:	06/18/2009
Last Update Date	:	05/08/2018

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