MEDICARE: EZEKIEL EARLY INTERVENTION SERVICES L.L.C.

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	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1265390348
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EZEKIEL EARLY INTERVENTION SERVICES L.L.C.

Provider Business Mailing Address
First Line	:	7445 ROOSEVELT RD APT 206-B
Second Line	:	7445
City	:	FOREST PARK
State	:	IL
Zip	:	60130-2555
Country	:	US
Telephone Number	:	773-850-5543
Fax Number	:	773-850-5543

Provider Business Practice Location Address
First Line	:	7445 ROOSEVELT RD APT 7445
Second Line	:
City	:	FOREST PARK
State	:	IL
Zip	:	60130-2555
Country	:	US
Telephone Number	:	773-850-5543
Fax Number	:	773-850-5543

Authorized Official
Title or Position	:	DEVELOPMENTAL THERAPIST
Name	:	LANETA CHANELLE JOHNSON
Credential	:	DT
Telephone Number	:	773-850-5543

Provider Enumeration Date	:	01/15/2026
Last Update Date	:	01/15/2026

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