MEDICARE: EZEKIEL EARLY CHILDHOOD DEVELOPMENT CENTER

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	:	1376309641
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EZEKIEL EARLY CHILDHOOD DEVELOPMENT CENTER

Provider Business Mailing Address
First Line	:	7445 ROOSEVELT RD APT 206-B
Second Line	:
City	:	FOREST PARK
State	:	IL
Zip	:	60130-2555
Country	:	US
Telephone Number	:	224-487-7400
Fax Number	:

Provider Business Practice Location Address
First Line	:	7445 ROOSEVELT RD APT 206-B
Second Line	:
City	:	FOREST PARK
State	:	IL
Zip	:	60130-2555
Country	:	US
Telephone Number	:	224-487-7400
Fax Number	:

Authorized Official
Title or Position	:	EARLY INTERVENTION SPECIALIST
Name	:	MISS LANETA CHANELLE JOHNSON
Credential	:	DT
Telephone Number	:	224-487-7400

Provider Enumeration Date	:	02/26/2024
Last Update Date	:	02/26/2024

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