Basic Information
| Provider Information | |||||||||
| NPI: | 1972172526 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANCIRA | ||||||||
| FirstName: | CASSIDY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4655 KIRCHOFF RD # 39 | ||||||||
| Address2: | |||||||||
| City: | ROLLING MEADOWS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600082070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473235536 | ||||||||
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| Practice Location | |||||||||
| Address1: | 917 SHERWOOD DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | LAKE BLUFF | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600442235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774864140 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2021 | ||||||||
| LastUpdateDate: | 08/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 103K00000X | 1-22-60792 | IL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.