Provider Demographics
NPI:1316498124
Name:BRAIN ABC'S
Entity type:Organization
Organization Name:BRAIN ABC'S
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DEVELOPMENTAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CAVALLO
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:708-805-0653
Mailing Address - Street 1:213 S PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-2535
Mailing Address - Country:US
Mailing Address - Phone:708-805-0653
Mailing Address - Fax:
Practice Address - Street 1:213 S PRINCETON AVE
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181-2535
Practice Address - Country:US
Practice Address - Phone:708-805-0653
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRAIN ABC'S
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1720290679OtherDEVELOPMENTAL THERAPIST
IL222Q00000XOtherTAXONOMY