Provider Demographics
NPI:1740644046
Name:LANDAU, ROSE (BCBA)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:LANDAU
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 1:8145 RIVER DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2660
Mailing Address - Country:US
Mailing Address - Phone:866-429-7543
Mailing Address - Fax:
Practice Address - Street 1:8145 RIVER DR
Practice Address - Street 2:SUITE 106
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-2660
Practice Address - Country:US
Practice Address - Phone:866-429-7543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-16-22318103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3000006OtherDHS DDD AS AN MCO PLAN