MEDICARE: BILLIE NOELL SWANSON RBT-18-47448

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	RBT-18-47448	IL

General Provider Information

NPI Number	:	1881184919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BILLIE NOELL SWANSON RBT-18-47448

Provider Business Mailing Address
First Line	:	4108 E LAKE SHORE DR
Second Line	:
City	:	WONDER LAKE
State	:	IL
Zip	:	60097-8398
Country	:	US
Telephone Number	:	815-403-6806
Fax Number	:

Provider Business Practice Location Address
First Line	:	4108 E LAKE SHORE DR
Second Line	:
City	:	WONDER LAKE
State	:	IL
Zip	:	60097-8398
Country	:	US
Telephone Number	:	815-403-6806
Fax Number	:

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

Provider Enumeration Date	:	05/14/2018
Last Update Date	:	05/14/2018

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