Provider Demographics
NPI:1740860915
Name:NIEBAUER, MADDOX (MS, BCBA)
Entity type:Individual
Prefix:
First Name:MADDOX
Middle Name:
Last Name:NIEBAUER
Suffix:
Gender:M
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 W WINCHESTER RD STE 108
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5312
Mailing Address - Country:US
Mailing Address - Phone:847-549-6139
Mailing Address - Fax:
Practice Address - Street 1:1860 W WINCHESTER RD STE 108
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5312
Practice Address - Country:US
Practice Address - Phone:847-573-9486
Practice Address - Fax:847-549-6139
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-22-62337103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst