Provider Demographics
NPI:1215480207
Name:MGM THERAPY & BEHAVIORAL TREATMENT CORPORATION
Entity type:Organization
Organization Name:MGM THERAPY & BEHAVIORAL TREATMENT CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEVELOPMENTAL THERAPY
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:GLYNISE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DT
Authorized Official - Phone:708-698-0714
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-0658
Mailing Address - Country:US
Mailing Address - Phone:708-724-5898
Mailing Address - Fax:
Practice Address - Street 1:12856 S PAULINA ST
Practice Address - Street 2:
Practice Address - City:CALUMET PARK
Practice Address - State:IL
Practice Address - Zip Code:60827-5951
Practice Address - Country:US
Practice Address - Phone:708-724-5898
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-26
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency