Provider Demographics
NPI:1033916119
Name:BEHRENDT, OWEN JOHN
Entity type:Individual
Prefix:
First Name:OWEN
Middle Name:JOHN
Last Name:BEHRENDT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4N224 FERSON CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1127
Mailing Address - Country:US
Mailing Address - Phone:630-360-0985
Mailing Address - Fax:
Practice Address - Street 1:1302 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3551
Practice Address - Country:US
Practice Address - Phone:309-452-0069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-24-402742106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician