Provider Demographics
NPI:1699271957
Name:PANIKKUTHARA, ANITTA REYNOLD (RBT-18-52795)
Entity type:Individual
Prefix:
First Name:ANITTA
Middle Name:REYNOLD
Last Name:PANIKKUTHARA
Suffix:
Gender:F
Credentials:RBT-18-52795
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6454 HATHAWAY LN
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-2435
Mailing Address - Country:US
Mailing Address - Phone:630-392-1433
Mailing Address - Fax:
Practice Address - Street 1:6454 HATHAWAY LN
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60516-2435
Practice Address - Country:US
Practice Address - Phone:630-392-1433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-18-52795106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician