Provider Demographics
NPI:1316533029
Name:PARK, ELLEN (RBT)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 BRIAN DR
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-7610
Mailing Address - Country:US
Mailing Address - Phone:224-522-9790
Mailing Address - Fax:
Practice Address - Street 1:1975 MCDOWELL RD
Practice Address - Street 2:101
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563
Practice Address - Country:US
Practice Address - Phone:331-229-8839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician