MEDICARE: EVENING STAR BEHAVIORAL SERVICE 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	251S00000X	Community/Behavioral Health Agency
2	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1821866559
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVENING STAR BEHAVIORAL SERVICE LLC

Provider Business Mailing Address
First Line	:	2405 ESSINGTON RD STE B539
Second Line	:
City	:	JOLIET
State	:	IL
Zip	:	60435-1200
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2405 ESSINGTON RD STE B539
Second Line	:
City	:	JOLIET
State	:	IL
Zip	:	60435-1200
Country	:	US
Telephone Number	:	301-523-6323
Fax Number	:

Authorized Official
Title or Position	:	REGISTERED AGENT
Name	:	KESHYRA MYERS
Credential	:
Telephone Number	:	301-523-6323

Provider Enumeration Date	:	12/12/2023
Last Update Date	:	12/12/2023

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