Provider Demographics
NPI:1922598119
Name:MIYASATO, CARLOS (RBT-16-25393)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:MIYASATO
Suffix:
Gender:M
Credentials:RBT-16-25393
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 E PRAIRIE BROOK DR APT C3
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60074-3175
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1227 E PRAIRIE BROOK DR APT C3
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60074-3175
Practice Address - Country:US
Practice Address - Phone:224-436-4964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
16-25393106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician