MEDICARE: DIANE MATHIAS RBT

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	17-36513	IL

General Provider Information

NPI Number	:	1518457563
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE MATHIAS RBT

Provider Business Mailing Address
First Line	:	6245 BIRMINGHAM ST
Second Line	:
City	:	CHICAGO RIDGE
State	:	IL
Zip	:	60415-1532
Country	:	US
Telephone Number	:	815-474-2282
Fax Number	:

Provider Business Practice Location Address
First Line	:	6245 BIRMINGHAM ST
Second Line	:
City	:	CHICAGO RIDGE
State	:	IL
Zip	:	60415-1532
Country	:	US
Telephone Number	:	815-474-2282
Fax Number	:

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

Provider Enumeration Date	:	05/15/2018
Last Update Date	:	05/15/2018

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Directions to “ DIANE MATHIAS RBT” Practice Location

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