MEDICARE: BRUNER & GLEASON THERAPEUTIC SERVICES

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	251S00000X	Community/Behavioral Health Agency	1962860080	IL

General Provider Information

NPI Number	:	1558725150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRUNER & GLEASON THERAPEUTIC SERVICES

Provider Business Mailing Address
First Line	:	1901 S CALUMET AVE
Second Line	:	UNIT 2308
City	:	CHICAGO
State	:	IL
Zip	:	60616-6044
Country	:	US
Telephone Number	:	773-931-8379
Fax Number	:

Provider Business Practice Location Address
First Line	:	1901 S CALUMET AVE
Second Line	:	UNIT 2308
City	:	CHICAGO
State	:	IL
Zip	:	60616-6044
Country	:	US
Telephone Number	:	773-931-8379
Fax Number	:

Authorized Official
Title or Position	:	MANAGER/OWNER
Name	:	MR. ANTON P GLEASON
Credential	:	LCPC
Telephone Number	:	773-931-8379

Provider Enumeration Date	:	04/09/2016
Last Update Date	:	04/09/2016

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