Provider Demographics
NPI:1396234894
Name:SHOULTZ, CARISSA (RBT-17-38260)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:SHOULTZ
Suffix:
Gender:F
Credentials:RBT-17-38260
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2602 N SAINT LOUIS AVE # 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-1216
Mailing Address - Country:US
Mailing Address - Phone:608-345-2474
Mailing Address - Fax:
Practice Address - Street 1:2602 N SAINT LOUIS AVE # 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-1216
Practice Address - Country:US
Practice Address - Phone:608-345-2474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL17-38260106S00000X
IL1-21-49774103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician