Provider Demographics
NPI:1245721547
Name:ICHTCHUK, DARIA (RBT)
Entity type:Individual
Prefix:
First Name:DARIA
Middle Name:
Last Name:ICHTCHUK
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-8713
Mailing Address - Country:US
Mailing Address - Phone:609-204-3966
Mailing Address - Fax:
Practice Address - Street 1:218 TRIANON LN
Practice Address - Street 2:
Practice Address - City:VILLANOVA
Practice Address - State:PA
Practice Address - Zip Code:19085-1442
Practice Address - Country:US
Practice Address - Phone:703-506-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-19-37763103K00000X
RBT-18-56331106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician