MEDICARE: AGNIESZKA GROCHOWSKA DT 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	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1881865517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGNIESZKA GROCHOWSKA DT INC

Provider Business Mailing Address
First Line	:	424 THUNDER RDG
Second Line	:
City	:	LAKE IN THE HILLS
State	:	IL
Zip	:	60156-4827
Country	:	US
Telephone Number	:	773-895-1367
Fax Number	:	847-658-3080

Provider Business Practice Location Address
First Line	:	424 THUNDER RDG
Second Line	:
City	:	LAKE IN THE HILLS
State	:	IL
Zip	:	60156-4827
Country	:	US
Telephone Number	:	773-895-1367
Fax Number	:	847-658-3080

Authorized Official
Title or Position	:	CDS
Name	:	MRS. AGNIESZKA AGATA GROCHOWSKA
Credential	:
Telephone Number	:	773-895-1367

Provider Enumeration Date	:	03/20/2008
Last Update Date	:	03/20/2008

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