Provider Demographics
NPI:1376309641
Name:EZEKIEL EARLY CHILDHOOD DEVELOPMENT CENTER
Entity Type:Organization
Organization Name:EZEKIEL EARLY CHILDHOOD DEVELOPMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EARLY INTERVENTION SPECIALIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:LANETA
Authorized Official - Middle Name:CHANELLE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DT
Authorized Official - Phone:224-487-7400
Mailing Address - Street 1:7445 ROOSEVELT RD APT 206-B
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-2555
Mailing Address - Country:US
Mailing Address - Phone:224-487-7400
Mailing Address - Fax:
Practice Address - Street 1:7445 ROOSEVELT RD APT 206-B
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-2555
Practice Address - Country:US
Practice Address - Phone:224-487-7400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty