MEDICARE: AUTISMCHICAGO

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	251C00000X	Developmentally Disabled Services Day Training Agency	103K00000X	IL

General Provider Information

NPI Number	:	1558818930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUTISMCHICAGO

Provider Business Mailing Address
First Line	:	8035 S WABASH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-3516
Country	:	US
Telephone Number	:	773-595-5168
Fax Number	:

Provider Business Practice Location Address
First Line	:	8035 S WABASH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-3516
Country	:	US
Telephone Number	:	773-595-5168
Fax Number	:

Authorized Official
Title or Position	:	BAHAVIORAL HEALTH TECHNICIAN
Name	:	TIFFANY COLE
Credential	:	MBA, MAP, BCBA, RBT
Telephone Number	:	773-595-5168

Provider Enumeration Date	:	09/02/2016
Last Update Date	:	09/02/2016

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Directions to “AUTISMCHICAGO ” Practice Location

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