MEDICARE: HEAVENLY INTERVENTIONS INC

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	103TB0200X	Cognitive & Behavioral Psychologist	036100047	IL

General Provider Information

NPI Number	:	1558497156
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEAVENLY INTERVENTIONS INC

Provider Business Mailing Address
First Line	:	7421 S SOUTH CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-2035
Country	:	US
Telephone Number	:	773-782-6173
Fax Number	:

Provider Business Practice Location Address
First Line	:	7421 S SOUTH CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-2035
Country	:	US
Telephone Number	:	773-782-6173
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. DEBRA SIMONE GAINES
Credential	:
Telephone Number	:	773-782-6173

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	10/28/2008

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