Healthcare Provider Details

I. General information

NPI: 1215480207
Provider Name (Legal Business Name): MGM THERAPY & BEHAVIORAL TREATMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12856 S PAULINA ST
CALUMET PARK IL
60827-5951
US

IV. Provider business mailing address

PO BOX 658
BLUE ISLAND IL
60406-0658
US

V. Phone/Fax

Practice location:
  • Phone: 708-724-5898
  • Fax:
Mailing address:
  • Phone: 708-724-5898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. MICHELLE GLYNISE MOORE
Title or Position: DEVELOPMENTAL THERAPY
Credential: DT
Phone: 708-698-0714