Basic Information
Provider Information | |||||||||
NPI: | 1417462045 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LAFLAIR | ||||||||
FirstName: | CORY | ||||||||
MiddleName: | KINSMAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | BCBA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LAMB | ||||||||
OtherFirstName: | CORY | ||||||||
OtherMiddleName: | KINSMAN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 530 W SURF ST APT 219 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606576039 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3133275484 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4433 W TOUHY AVE | ||||||||
Address2: |   | ||||||||
City: | LINCOLNWOOD | ||||||||
State: | IL | ||||||||
PostalCode: | 607121820 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8774864140 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/05/2017 | ||||||||
LastUpdateDate: | 12/05/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X |   |   | Y |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
No ID Information.