Provider Demographics
NPI:1720577232
Name:TINDALL, LARISSA (BCBA)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:TINDALL
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8609 W BRYN MAWR AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3524
Mailing Address - Country:US
Mailing Address - Phone:773-726-1416
Mailing Address - Fax:
Practice Address - Street 1:8609 W BRYN MAWR AVE STE 204
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3524
Practice Address - Country:US
Practice Address - Phone:773-726-1416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103K00000X
103K00000X, 156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No156F00000XEye and Vision Services ProvidersTechnician/Technologist