Provider Demographics
NPI:1194168823
Name:INDIVISUAL ABA
Entity type:Organization
Organization Name:INDIVISUAL ABA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-317-9688
Mailing Address - Street 1:1984 SEDGEGRASS TRL
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-4329
Mailing Address - Country:US
Mailing Address - Phone:217-317-9688
Mailing Address - Fax:
Practice Address - Street 1:1984 SEDGEGRASS TRL
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4329
Practice Address - Country:US
Practice Address - Phone:217-317-9688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty