Provider Demographics
NPI:1790452720
Name:AUSTIN, MICHAELA
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8232 S PEORIA ST FL 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-3149
Mailing Address - Country:US
Mailing Address - Phone:901-628-5048
Mailing Address - Fax:
Practice Address - Street 1:975 W HAWTHORN DR
Practice Address - Street 2:
Practice Address - City:ITASCA
Practice Address - State:IL
Practice Address - Zip Code:60143-2056
Practice Address - Country:US
Practice Address - Phone:800-844-1232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-21-181633106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician