Basic Information
| Provider Information | |||||||||
| NPI: | 1407410426 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EBERLEIN | ||||||||
| FirstName: | MARIN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 LEE ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600166574 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4433 W TOUHY AVE # 335 | ||||||||
| Address2: | |||||||||
| City: | LINCOLNWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607121820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774864140 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2019 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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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 | 1-19-35112 | CO | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.