MEDICARE: BRYAN MICHAEL GRUENEBERG RBT

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	106S00000X	Behavior Technician	17-45174	IL

General Provider Information

NPI Number	:	1417447152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYAN MICHAEL GRUENEBERG RBT

Provider Business Mailing Address
First Line	:	725 HILL DR APT 206
Second Line	:
City	:	HOFFMAN ESTATES
State	:	IL
Zip	:	60169-1421
Country	:	US
Telephone Number	:	847-436-1342
Fax Number	:

Provider Business Practice Location Address
First Line	:	725 HILL DR APT 206
Second Line	:
City	:	HOFFMAN ESTATES
State	:	IL
Zip	:	60169-1421
Country	:	US
Telephone Number	:	847-436-1342
Fax Number	:

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

Provider Enumeration Date	:	05/17/2018
Last Update Date	:	05/17/2018

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