MEDICARE: SOUTH LOOP PEDIATRIC THERAPY 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	252Y00000X	Early Intervention Provider Agency	070.013558	IL
2	2251P0200X	Pediatric Physical Therapist	070.013558	IL

General Provider Information

NPI Number	:	1356677462
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH LOOP PEDIATRIC THERAPY LLC

Provider Business Mailing Address
First Line	:	1515 S PRAIRIE AVE
Second Line	:	UNIT 603
City	:	CHICAGO
State	:	IL
Zip	:	60605-3043
Country	:	US
Telephone Number	:	773-733-1695
Fax Number	:	773-435-6595

Provider Business Practice Location Address
First Line	:	1515 S PRAIRIE AVE
Second Line	:	UNIT 603
City	:	CHICAGO
State	:	IL
Zip	:	60605-3043
Country	:	US
Telephone Number	:	773-733-1695
Fax Number	:	773-435-6595

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	MRS. JANA MARLENE SUSIE
Credential	:	P.T.
Telephone Number	:	773-733-1695

Provider Enumeration Date	:	10/23/2009
Last Update Date	:	10/23/2009

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Directions to “SOUTH LOOP PEDIATRIC THERAPY LLC ” Practice Location

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