Provider Demographics
NPI:1396219705
Name:OTTO, SARA CHRISTINE (BCBA 01-20-42117)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:CHRISTINE
Last Name:OTTO
Suffix:
Gender:F
Credentials:BCBA 01-20-42117
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2815 CATTAIL CT UNIT A
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-5069
Mailing Address - Country:US
Mailing Address - Phone:224-201-6072
Mailing Address - Fax:
Practice Address - Street 1:1870 W WINCHESTER RD STE 203
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5360
Practice Address - Country:US
Practice Address - Phone:847-816-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-18-9266106E00000X
1-20-42117103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst