MEDICARE: MGM THERAPY & BEHAVIORAL TREATMENT CORPORATION

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

General Provider Information

NPI Number	:	1215480207
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MGM THERAPY & BEHAVIORAL TREATMENT CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 658
Second Line	:
City	:	BLUE ISLAND
State	:	IL
Zip	:	60406-0658
Country	:	US
Telephone Number	:	708-724-5898
Fax Number	:

Provider Business Practice Location Address
First Line	:	12856 S PAULINA ST
Second Line	:
City	:	CALUMET PARK
State	:	IL
Zip	:	60827-5951
Country	:	US
Telephone Number	:	708-724-5898
Fax Number	:

Authorized Official
Title or Position	:	DEVELOPMENTAL THERAPY
Name	:	MS. MICHELLE GLYNISE MOORE
Credential	:	DT
Telephone Number	:	708-698-0714

Provider Enumeration Date	:	07/26/2016
Last Update Date	:	07/27/2016

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