Basic Information
Provider Information | |||||||||
NPI: | 1104583954 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BIXLER | ||||||||
FirstName: | JENELLE | ||||||||
MiddleName: | RENAE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LOTTNER | ||||||||
OtherFirstName: | JENELLE | ||||||||
OtherMiddleName: | RENAE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | BEHAVIOR TECHNICIAN | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | WESTSIDE CHILDREN'S THERAPY | ||||||||
Address2: | 1725 S NAPERVILLE RD STE 110 | ||||||||
City: | WHEATON | ||||||||
State: | IL | ||||||||
PostalCode: | 60189 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6305094911 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 21000 S FRANKFORT SQUARE RD | ||||||||
Address2: |   | ||||||||
City: | FRANKFORT | ||||||||
State: | IL | ||||||||
PostalCode: | 604239385 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8154691500 | ||||||||
FaxNumber: | 8152205619 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/29/2021 | ||||||||
LastUpdateDate: | 11/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X |   |   | Y |   |   |   |   |
No ID Information.