Provider Demographics
NPI:1316781859
Name:NIETO, ELIJAH RAUL (BFA)
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:RAUL
Last Name:NIETO
Suffix:
Gender:M
Credentials:BFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 38TH AVE STE F-I
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5411
Mailing Address - Country:US
Mailing Address - Phone:630-509-8700
Mailing Address - Fax:
Practice Address - Street 1:255 38TH AVE STE F-I
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5411
Practice Address - Country:US
Practice Address - Phone:630-509-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-24-353576106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician