Provider Demographics
NPI:1285146092
Name:PEBBLEBROOK PEDIATRIC BEHAVIORAL THERAPY, LLC
Entity type:Organization
Organization Name:PEBBLEBROOK PEDIATRIC BEHAVIORAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/BCBA
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:D
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:847-752-0046
Mailing Address - Street 1:1301 PYOTT RD STE 106
Mailing Address - Street 2:
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-9796
Mailing Address - Country:US
Mailing Address - Phone:847-752-0046
Mailing Address - Fax:224-678-9886
Practice Address - Street 1:1301 PYOTT RD STE 106
Practice Address - Street 2:
Practice Address - City:LAKE IN THE HILLS
Practice Address - State:IL
Practice Address - Zip Code:60156-9796
Practice Address - Country:US
Practice Address - Phone:847-752-0046
Practice Address - Fax:224-678-9886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-02
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-17-27622103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty