Provider Demographics
NPI:1487150702
Name:WAWRZONKOWSKI, RICHARD (BCABA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WAWRZONKOWSKI
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:937 NORTHWAY CT
Mailing Address - Street 2:
Mailing Address - City:HANOVER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60133-2648
Mailing Address - Country:US
Mailing Address - Phone:224-830-0515
Mailing Address - Fax:
Practice Address - Street 1:25 N RIVER LN STE 2109
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2003
Practice Address - Country:US
Practice Address - Phone:331-222-7724
Practice Address - Fax:844-447-0582
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst