Basic Information
| Provider Information | |||||||||
| NPI: | 1093179830 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOODS | ||||||||
| FirstName: | TANISHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 LEE ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600166574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774864140 | ||||||||
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| Practice Location | |||||||||
| Address1: | 917 SHERWOOD DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | LAKE BLUFF | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600442224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774864140 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2016 | ||||||||
| LastUpdateDate: | 01/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-16-21722 | IL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 103K00000X | 01 | IL | AUTISM HOME SUPPORT | OTHER |