Provider Demographics
NPI:1447722145
Name:MALESH, MICHAEL (RBT-18-73837)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:MALESH
Suffix:
Gender:M
Credentials:RBT-18-73837
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 REVERE DR STE 120
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-8005
Mailing Address - Country:US
Mailing Address - Phone:847-306-9843
Mailing Address - Fax:
Practice Address - Street 1:5 REVERE DR STE 120
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-8005
Practice Address - Country:US
Practice Address - Phone:847-306-9843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL18-73837106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician