Provider Demographics
NPI:1841973963
Name:TANEDO, MYLA
Entity type:Individual
Prefix:
First Name:MYLA
Middle Name:
Last Name:TANEDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14816 MONTGOMERY DRIVE
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462
Mailing Address - Country:US
Mailing Address - Phone:708-253-5106
Mailing Address - Fax:
Practice Address - Street 1:5801 MOUNT PLEASANT LN
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3944
Practice Address - Country:US
Practice Address - Phone:314-560-7063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst