Provider Demographics
NPI:1629025044
Name:BARDELL, RAE (BCBA, LCSWM)
Entity Type:Individual
Prefix:
First Name:RAE
Middle Name:
Last Name:BARDELL
Suffix:
Gender:F
Credentials:BCBA, LCSWM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 S STANTON ST
Mailing Address - Street 2:
Mailing Address - City:SHANNON
Mailing Address - State:IL
Mailing Address - Zip Code:61078-9311
Mailing Address - Country:US
Mailing Address - Phone:815-291-3887
Mailing Address - Fax:
Practice Address - Street 1:1761 WOODGATE DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-2770
Practice Address - Country:US
Practice Address - Phone:920-206-4505
Practice Address - Fax:815-827-6202
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-18-30939103K00000X
1041S0200X
IL149.0145361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool