Provider Demographics
NPI:1164911715
Name:PETERSON, BRIANNA (RBT-18-48032)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RBT-18-48032
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 CROSSLAND DR
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-7810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 N LOOMIS ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-1147
Practice Address - Country:US
Practice Address - Phone:312-243-8487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL18-48032106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician