Provider Demographics
NPI:1992269856
Name:SANDER, KELLI (RBT-18-71726)
Entity type:Individual
Prefix:MS
First Name:KELLI
Middle Name:
Last Name:SANDER
Suffix:
Gender:F
Credentials:RBT-18-71726
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6N200 MEDINAH RD
Mailing Address - Street 2:
Mailing Address - City:MEDINAH
Mailing Address - State:IL
Mailing Address - Zip Code:60157-9743
Mailing Address - Country:US
Mailing Address - Phone:847-525-4999
Mailing Address - Fax:
Practice Address - Street 1:6N200 MEDINAH RD
Practice Address - Street 2:
Practice Address - City:MEDINAH
Practice Address - State:IL
Practice Address - Zip Code:60157-9743
Practice Address - Country:US
Practice Address - Phone:847-525-4999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-18-71726106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician