Provider Demographics
NPI:1518096064
Name:BERTLING, MYRA J (BEHAVIOR ANALYST)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:J
Last Name:BERTLING
Suffix:
Gender:F
Credentials:BEHAVIOR ANALYST
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1750 APPLE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-6509
Mailing Address - Country:US
Mailing Address - Phone:630-217-1292
Mailing Address - Fax:630-759-4228
Practice Address - Street 1:1750 APPLE VALLEY RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-6509
Practice Address - Country:US
Practice Address - Phone:630-217-1292
Practice Address - Fax:630-759-4228
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225800000X, 222Q00000X
IL1-16-23471103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist