Provider Demographics
NPI:1467689364
Name:PACHECO, DYANNA ISHTAR (RBT-17-31942)
Entity Type:Individual
Prefix:
First Name:DYANNA
Middle Name:ISHTAR
Last Name:PACHECO
Suffix:
Gender:F
Credentials:RBT-17-31942
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 W PEBBLE BEACH CIR APT 301
Mailing Address - Street 2:
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-3625
Mailing Address - Country:US
Mailing Address - Phone:312-961-2567
Mailing Address - Fax:
Practice Address - Street 1:12 W PEBBLE BEACH CIR APT 301
Practice Address - Street 2:
Practice Address - City:GLENDALE HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60139-3625
Practice Address - Country:US
Practice Address - Phone:312-961-2567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-18
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL17-31942106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician