Provider Demographics
NPI:1154995413
Name:DONNELLY, TAYLOR M (BCBA)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:M
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8609 W BRYN MAWR AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3524
Mailing Address - Country:US
Mailing Address - Phone:773-644-7787
Mailing Address - Fax:
Practice Address - Street 1:8200 185TH ST
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60487-9232
Practice Address - Country:US
Practice Address - Phone:708-580-0440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-19
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-21-49677103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst