Provider Demographics
NPI:1851843585
Name:BRUSVEN, GATSBY (BCBA)
Entity Type:Individual
Prefix:
First Name:GATSBY
Middle Name:
Last Name:BRUSVEN
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 1:3815 E MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2488
Mailing Address - Country:US
Mailing Address - Phone:630-584-7530
Mailing Address - Fax:
Practice Address - Street 1:3815 E MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2488
Practice Address - Country:US
Practice Address - Phone:630-584-7530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-28
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-15-01607106S00000X
IL1-18-29706103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician