MEDICARE: MYC HOLDINGS LLC

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

General Provider Information

NPI Number	:	1568884732
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MYC HOLDINGS LLC

Provider Business Mailing Address
First Line	:	500 W SILVER SPRING DR
Second Line	:	SUITE 200
City	:	GLENDALE
State	:	WI
Zip	:	53217-5051
Country	:	US
Telephone Number	:	414-847-6253
Fax Number	:	414-501-2361

Provider Business Practice Location Address
First Line	:	500 W SILVER SPRING DR
Second Line	:	SUITE 200
City	:	GLENDALE
State	:	WI
Zip	:	53217-5051
Country	:	US
Telephone Number	:	414-847-6253
Fax Number	:	414-501-2361

Authorized Official
Title or Position	:	CLINIC DIRECTOR
Name	:	MR. MITCHELL COHEN
Credential	:	PCTL, SACIT
Telephone Number	:	414-847-6253

Provider Enumeration Date	:	01/07/2014
Last Update Date	:	06/24/2014

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