Provider Demographics
NPI:1972058311
Name:BAENZIGER, AUDREY (BCBA)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:BAENZIGER
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 1:29854 OAK MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60145-8538
Mailing Address - Country:US
Mailing Address - Phone:815-739-5244
Mailing Address - Fax:815-895-2270
Practice Address - Street 1:29854 OAK MEADOW DR
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:IL
Practice Address - Zip Code:60145-8538
Practice Address - Country:US
Practice Address - Phone:815-739-5244
Practice Address - Fax:815-895-2270
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-15-20703103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst