Provider Demographics
NPI:1790047611
Name:GAUGHAN, ALISSA ANN (BCBA)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:ANN
Last Name:GAUGHAN
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 1:345 E OHIO ST
Mailing Address - Street 2:APT 1401
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3375
Mailing Address - Country:US
Mailing Address - Phone:517-262-4261
Mailing Address - Fax:
Practice Address - Street 1:2323 NAPERVILLE RD
Practice Address - Street 2:SUITE 265
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-3444
Practice Address - Country:US
Practice Address - Phone:331-457-5533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-12-9896103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst