MEDICARE: BRANDON BIGBY, LMFT, 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	106H00000X	Marriage & Family Therapist	166000979	IL

General Provider Information

NPI Number	:	1407226103
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRANDON BIGBY, LMFT, LLC

Provider Business Mailing Address
First Line	:	5100 N RAVENSWOOD AVE
Second Line	:	SUITE 217
City	:	CHICAGO
State	:	IL
Zip	:	60640-2713
Country	:	US
Telephone Number	:	773-564-9763
Fax Number	:	773-250-3575

Provider Business Practice Location Address
First Line	:	5100 N RAVENSWOOD AVE
Second Line	:	SUITE 217
City	:	CHICAGO
State	:	IL
Zip	:	60640-2713
Country	:	US
Telephone Number	:	773-564-9763
Fax Number	:	773-250-3575

Authorized Official
Title or Position	:	OWNER
Name	:	MR. BRANDON BIGBY
Credential	:	LMFT
Telephone Number	:	773-564-9763

Provider Enumeration Date	:	10/07/2015
Last Update Date	:	10/07/2015

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