Provider Demographics
NPI:1912709700
Name:CAIN, SIMONE BOLIVAR
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:BOLIVAR
Last Name:CAIN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 W ROOSEVELT RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WEST CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60185-4819
Mailing Address - Country:US
Mailing Address - Phone:224-760-1182
Mailing Address - Fax:
Practice Address - Street 1:29 STONEHILL RD # D
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-9449
Practice Address - Country:US
Practice Address - Phone:224-760-1182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL652591106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician