Provider Demographics
NPI:1992295182
Name:JANNUSCH, LESLIE (BCBA# 1-18-33737)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:JANNUSCH
Suffix:
Gender:F
Credentials:BCBA# 1-18-33737
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 ANGELA CT
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1709
Mailing Address - Country:US
Mailing Address - Phone:847-997-2296
Mailing Address - Fax:
Practice Address - Street 1:302 ANGELA CT
Practice Address - Street 2:
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1709
Practice Address - Country:US
Practice Address - Phone:847-997-2296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-18-33737103K00000X
IL16-23039106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician