Great Lakes Behavioral Services

Primary specialty

Behavior AnalystTaxonomy code 103K00000X

Legal business name

GREAT LAKES BEHAVIORAL SERVICES

Practice address

701 N Niles Ave
South Bend, IN 46617-1923

Phone

(574) 393-9955

Fax

(574) 393-9956

NPI assigned

Jan 5, 2021

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Shanti Bradley, BCBANPI 1760924716

Title

Co-Clinical Director

Phone

(574) 393-9955

Specialties & licenses 1

Addresses

Electronic endpoints 1

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Shanti Bradley, M.ED., MBA, BCBA

  • Behavior Analyst
  • South Bend, IN
  • NPI 1760924716
  NPD Authorized official
• Leena Bradley

  • Behavior Technician
  • South Bend, IN
  • NPI 1962370650
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1609804800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1624838400000",
    "number": "1144818295",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "701 N NILES AVE STE OP102",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466171923",
            "telephone_number": "574-393-9955",
            "fax_number": "574-393-9956"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "701 N NILES AVE",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466171923",
            "telephone_number": "574-393-9955",
            "fax_number": "574-393-9956"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREAT LAKES BEHAVIORAL SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-01-05",
        "last_updated": "2021-06-28",
        "certification_date": "2021-06-28",
        "status": "A",
        "authorized_official_last_name": "BRADLEY",
        "authorized_official_first_name": "SHANTI",
        "authorized_official_title_or_position": "CO-CLINICAL DIRECTOR",
        "authorized_official_telephone_number": "574-393-9955",
        "authorized_official_credential": "BCBA"
    },
    "taxonomies": [
        {
            "code": "103K00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Behavior Analyst",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "info@glbehavioral.com",
            "affiliation": "N",
            "endpointDescription": "Direct Office Email",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "Email",
            "address_1": "701 N Niles Ave",
            "city": "South Bend",
            "state": "IN",
            "country_code": "US",
            "postal_code": "466171923",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Kenya G Grajeda
• Gabrianna Gratzol, RBT
• Aaron T Gray, MA
• Whitney Gray, RBT
• Marci Grayson, MA, LMHC
• Alexis Danielle Green, DNP
• Dawn M Green, MSW
• Echo Marie Green, RBT
• Ellyssa Green, MSW, LCSW
• Mark Raymond Green, D.D.S.

• Behavior Analyst in South Bend, IN
• Providers in South Bend, IN by specialty
• Behavior Analyst in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 28, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.