MEDICARE: OCTAVE BEHAVIORAL MICHIGAN PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist

General Provider Information

NPI Number	:	1306655485
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OCTAVE BEHAVIORAL MICHIGAN PC

Provider Business Mailing Address
First Line	:	PO BOX 18481
Second Line	:
City	:	PALATINE
State	:	IL
Zip	:	60055-8481
Country	:	US
Telephone Number	:	415-360-3833
Fax Number	:	628-234-3048

Provider Business Practice Location Address
First Line	:	3366 RIVERSIDE DR STE 103
Second Line	:
City	:	UPPER ARLINGTON
State	:	OH
Zip	:	43221-1734
Country	:	US
Telephone Number	:	415-360-3833
Fax Number	:	628-234-3048

Authorized Official
Title or Position	:	VP REVENUE OPERATIONS
Name	:	KYM EVERETT
Credential	:
Telephone Number	:	650-504-2289

Provider Enumeration Date	:	01/03/2025
Last Update Date	:	01/03/2025

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