Provider Demographics
NPI:1003214487
Name:GLAVIN, TARA (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:GLAVIN
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 W GRAND AVE
Mailing Address - Street 2:UNIT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-8873
Mailing Address - Country:US
Mailing Address - Phone:847-477-7729
Mailing Address - Fax:
Practice Address - Street 1:1420 W GRAND AVE
Practice Address - Street 2:UNIT 2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-8873
Practice Address - Country:US
Practice Address - Phone:847-477-7729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-08-4015103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst