MEDICARE: PREVENTIVE DEVELOPMENT DISABILITY AND HEALTH SERVICES LLC

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1245112978
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREVENTIVE DEVELOPMENT DISABILITY AND HEALTH SERVICES LLC

Provider Business Mailing Address
First Line	:	2481 MAYFIELD DR
Second Line	:
City	:	MONTGOMERY
State	:	IL
Zip	:	60538-5057
Country	:	US
Telephone Number	:	331-250-2492
Fax Number	:

Provider Business Practice Location Address
First Line	:	2481 MAYFIELD DR
Second Line	:
City	:	MONTGOMERY
State	:	IL
Zip	:	60538-5057
Country	:	US
Telephone Number	:	331-250-2492
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT - DIRECTOR
Name	:	MS. CONSTANCE ETENGENENG NGASSA
Credential	:	RN
Telephone Number	:	331-250-2492

Provider Enumeration Date	:	07/23/2025
Last Update Date	:	07/23/2025

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