Provider Demographics
NPI:1639660293
Name:GEBRE, ELIJAH DON (RBT-18-49343)
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:DON
Last Name:GEBRE
Suffix:
Gender:M
Credentials:RBT-18-49343
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7023 FOSTER ST
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-1213
Mailing Address - Country:US
Mailing Address - Phone:773-849-8642
Mailing Address - Fax:
Practice Address - Street 1:7023 FOSTER ST
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-1213
Practice Address - Country:US
Practice Address - Phone:773-849-8642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-19
Last Update Date:2018-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-18-49343106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician