Provider Demographics
NPI:1740522549
Name:IMPACTING AUTISM, LLC
Entity type:Organization
Organization Name:IMPACTING AUTISM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD CERTIFIED BEHAVIOR ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:DIANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:POULOS
Authorized Official - Suffix:
Authorized Official - Credentials:MA,BCBA
Authorized Official - Phone:847-331-5370
Mailing Address - Street 1:1613 W COLONIAL PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INVERNESS
Mailing Address - State:IL
Mailing Address - Zip Code:60067-4827
Mailing Address - Country:US
Mailing Address - Phone:847-331-5370
Mailing Address - Fax:847-202-1150
Practice Address - Street 1:1613 W COLONIAL PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:INVERNESS
Practice Address - State:IL
Practice Address - Zip Code:60067-4827
Practice Address - Country:US
Practice Address - Phone:847-331-5370
Practice Address - Fax:847-202-1150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-20
Last Update Date:2016-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-09-6494103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty