Provider Demographics
NPI:1952858409
Name:BENNETT, MARISSA (BCBA)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:BENNETT
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 1:666 DUNDEE RD STE 1605
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2738
Mailing Address - Country:US
Mailing Address - Phone:847-495-2640
Mailing Address - Fax:847-324-2184
Practice Address - Street 1:666 DUNDEE RD STE 1605
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2738
Practice Address - Country:US
Practice Address - Phone:847-495-2640
Practice Address - Fax:473-242-1848
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-15-18740103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst