MEDICARE: KIRBY JOHNSON

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1386036564
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIRBY JOHNSON

Provider Business Mailing Address
First Line	:	3807 N LEAVITT ST APT 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-3825
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3807 N LEAVITT ST APT 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-3825
Country	:	US
Telephone Number	:	309-360-6268
Fax Number	:

Authorized Official
Title or Position	:	BEHAVIOR ANALYST
Name	:	KIRBY JOHNSON
Credential	:
Telephone Number	:	309-360-6268

Provider Enumeration Date	:	02/25/2015
Last Update Date	:	02/25/2015

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Directions to “KIRBY JOHNSON ” Practice Location

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