MEDICARE: BRIAN MANBURG

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	103K00000X	Behavior Analyst	1-21-49959	IL

General Provider Information

NPI Number	:	1316181530
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN MANBURG

Provider Business Mailing Address
First Line	:	PO BOX 639561
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-9561
Country	:	US
Telephone Number	:	844-247-7222
Fax Number	:	215-489-8766

Provider Business Practice Location Address
First Line	:	2762 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2425
Country	:	US
Telephone Number	:	844-247-7222
Fax Number	:	215-489-8766

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2009
Last Update Date	:	08/12/2021

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Directions to “ BRIAN MANBURG ” Practice Location

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