MEDICARE: BEGINNERS DEPOOT ECE CONSULTING

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	252Y00000X	Early Intervention Provider Agency	TJ35590103P	IL

General Provider Information

NPI Number	:	1043592801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEGINNERS DEPOOT ECE CONSULTING

Provider Business Mailing Address
First Line	:	346 W 113TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60628-4137
Country	:	US
Telephone Number	:	773-495-5152
Fax Number	:

Provider Business Practice Location Address
First Line	:	346 W 113TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60628-4137
Country	:	US
Telephone Number	:	773-495-5152
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. TYWANDA M JILES
Credential	:	EDD, DT
Telephone Number	:	773-710-6897

Provider Enumeration Date	:	09/16/2011
Last Update Date	:	09/16/2011

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Directions to “BEGINNERS DEPOOT ECE CONSULTING ” Practice Location

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