MEDICARE: DRLULLABY 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	103TB0200X	Cognitive & Behavioral Psychologist
2	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1790499838
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DRLULLABY LLC

Provider Business Mailing Address
First Line	:	1440 W TAYLOR ST # 556
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60607-4623
Country	:	US
Telephone Number	:	844-475-3379
Fax Number	:	855-644-2986

Provider Business Practice Location Address
First Line	:	3479 NE 163RD ST STE 1208
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33160-4426
Country	:	US
Telephone Number	:	844-475-3379
Fax Number	:	855-644-2986

Authorized Official
Title or Position	:	CEO
Name	:	LISA ANN MEDALIE
Credential	:
Telephone Number	:	619-997-5759

Provider Enumeration Date	:	01/12/2023
Last Update Date	:	03/27/2023

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