MEDICARE: ALLY PEDIATRIC THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	106E00000X	Assistant Behavior Analyst
2	106S00000X	Behavior Technician
3	235Z00000X	Speech-Language Pathologist
4	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1114688629
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLY PEDIATRIC THERAPY LLC

Provider Business Mailing Address
First Line	:	2301 E YEAGER DR STE 14
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85286-1578
Country	:	US
Telephone Number	:	480-374-3175
Fax Number	:	844-475-2307

Provider Business Practice Location Address
First Line	:	2301 E YEAGER DR STE 14
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85286-1578
Country	:	US
Telephone Number	:	480-374-3175
Fax Number	:	844-475-2307

Authorized Official
Title or Position	:	CEO
Name	:	ANTHONY MACLEOD
Credential	:
Telephone Number	:	602-606-2237

Provider Enumeration Date	:	01/06/2022
Last Update Date	:	01/06/2022

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