Provider Demographics
NPI:1467058404
Name:CULTIVATE BEHAVIORAL HEALTH AND EDUCATION- ILLINOIS
Entity Type:Organization
Organization Name:CULTIVATE BEHAVIORAL HEALTH AND EDUCATION- ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OZZIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMGREN
Authorized Official - Suffix:
Authorized Official - Credentials:MED, BCBA
Authorized Official - Phone:631-804-4268
Mailing Address - Street 1:11055 S NAGLE AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:WORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60482-1655
Mailing Address - Country:US
Mailing Address - Phone:224-703-0502
Mailing Address - Fax:
Practice Address - Street 1:11055 S NAGLE AVE APT 5
Practice Address - Street 2:
Practice Address - City:WORTH
Practice Address - State:IL
Practice Address - Zip Code:60482-1655
Practice Address - Country:US
Practice Address - Phone:224-703-0502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-06
Last Update Date:2020-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty