1396177440 NPI number — MS. MARISSA JEAN TYBOR M.A., BCBA

Table of content: MS. MARISSA JEAN TYBOR M.A., BCBA (NPI 1396177440)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396177440 NPI number — MS. MARISSA JEAN TYBOR M.A., BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TYBOR
Provider First Name:
MARISSA
Provider Middle Name:
JEAN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.A., BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396177440
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 CHESTERFIELD CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOURBONNAIS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60914-9651
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-518-9556
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
551 EASTPORT CENTRE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALPARAISO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46383-2898
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-255-2454
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-16-22178 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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