MEDICARE: TIME TO SHINE ABA LLC

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	:	1649983032
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIME TO SHINE ABA LLC

Provider Business Mailing Address
First Line	:	21 BOULDER HILL PASS
Second Line	:
City	:	MONTGOMERY
State	:	IL
Zip	:	60538-1911
Country	:	US
Telephone Number	:	630-331-3667
Fax Number	:

Provider Business Practice Location Address
First Line	:	21 BOULDER HILL PASS
Second Line	:
City	:	MONTGOMERY
State	:	IL
Zip	:	60538-1911
Country	:	US
Telephone Number	:	630-331-3667
Fax Number	:

Authorized Official
Title or Position	:	BCBA
Name	:	CAITLYN WYSOGLAD
Credential	:	MA, BCBA
Telephone Number	:	630-779-3029

Provider Enumeration Date	:	12/30/2022
Last Update Date	:	09/10/2024

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