MEDICARE: VENTZISLAVA MARTIN 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

General Provider Information

NPI Number	:	1649605213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VENTZISLAVA MARTIN BCBA

Provider Business Mailing Address
First Line	:	26804 BASSWOOD CIR
Second Line	:
City	:	PLAINFIELD
State	:	IL
Zip	:	60585-2932
Country	:	US
Telephone Number	:	630-404-6545
Fax Number	:

Provider Business Practice Location Address
First Line	:	6860 N FRONTAGE RD STE A
Second Line	:
City	:	BURR RIDGE
State	:	IL
Zip	:	60527-7828
Country	:	US
Telephone Number	:	331-210-9210
Fax Number	:

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

Provider Enumeration Date	:	09/13/2013
Last Update Date	:	01/04/2022

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