Healthcare Provider Details

I. General information

NPI: 1316505126
Provider Name (Legal Business Name): MEGAN HOLBACH DT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4735 N KELSO AVE
CHICAGO IL
60630-4353
US

IV. Provider business mailing address

4735 N KELSO AVE
CHICAGO IL
60630-4353
US

V. Phone/Fax

Practice location:
  • Phone: 773-414-3856
  • Fax:
Mailing address:
  • Phone: 773-414-3856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-64586
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: