Provider Demographics
NPI:1790264927
Name:INDEPENDENT WITH AUTISM
Entity Type:Organization
Organization Name:INDEPENDENT WITH AUTISM
Other - Org Name:INDEPENDENT WITH AUTISM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PERKOWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-274-9413
Mailing Address - Street 1:2549 WAUKEGAN RD STE 55
Mailing Address - Street 2:
Mailing Address - City:BANNOCKBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60015-1569
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 SAUNDERS RD STE 150
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-2526
Practice Address - Country:US
Practice Address - Phone:847-275-9413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIND BODY LIFE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty