Provider Demographics
NPI:1093957698
Name:BLACKETT, REBECCA ANN (MS, BCBA)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:ANN
Last Name:BLACKETT
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8609 W BRYN MAWR AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3524
Mailing Address - Country:US
Mailing Address - Phone:773-726-1416
Mailing Address - Fax:
Practice Address - Street 1:14701 S LA GRANGE RD FL 2
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3226
Practice Address - Country:US
Practice Address - Phone:224-470-0057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-27
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1-08-4267103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst