MEDICARE: PROVIDER CONNECTION

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	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1447521414
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDER CONNECTION

Provider Business Mailing Address
First Line	:	1036 N HAMLIN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60651-3830
Country	:	US
Telephone Number	:	773-853-9832
Fax Number	:

Provider Business Practice Location Address
First Line	:	1036 N. HAMLIN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60651-3830
Country	:	US
Telephone Number	:	773-853-9832
Fax Number	:

Authorized Official
Title or Position	:	DEVELOPMENTAL THERAPIST
Name	:	MS. DONNA MARIE MITCHEM
Credential	:
Telephone Number	:	773-853-9832

Provider Enumeration Date	:	01/23/2012
Last Update Date	:	01/23/2012

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