MEDICARE: T SOUTHWARD

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

General Provider Information

NPI Number	:	1447312152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	T SOUTHWARD

Provider Business Mailing Address
First Line	:	6808 N WOLCOTT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-3155
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6808 N WOLCOTT AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-3155
Country	:	US
Telephone Number	:	773-456-5640
Fax Number	:

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

Provider Enumeration Date	:	12/16/2006
Last Update Date	:	03/14/2009

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Directions to “ T SOUTHWARD ” Practice Location

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