=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780118836
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCGILL CENTER FOR INDEPENDENT LIVING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2017
-----------------------------------------------------
Last Update Date | 04/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 920 SOUTHLAKES WAY SW
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32968-7526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-559-7349
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 920 SOUTHLAKES WAY SW
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32968-7526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-559-7349
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MS. LAURA ANN MCGILL
-----------------------------------------------------
Credential | BCBA
-----------------------------------------------------
Telephone | 772-559-7349
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------