Basic Information
| Provider Information | |||||||||
| NPI: | 1811521164 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANNICI | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | ASHLEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 FINLEY RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605151394 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2901 FINLEY RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605151394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154691500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2020 | ||||||||
| LastUpdateDate: | 05/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 2020034220 | MO | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106S00000X | RBT-18-54686 | MO | N | 193400000X SINGLE SPECIALTY GROUP | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.