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NPI Code Detail

MEDICARE: EVERGREEN PEDIATRIC THERAPY LLC

MEDICARE: EVERGREEN 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
12251P0200XPediatric Physical Therapist
2225XP0200XPediatric Occupational Therapist
3235Z00000XSpeech-Language Pathologist146.0009085IL

General Provider Information

NPI Number : 1659888931
Entity Type Code : Organization
Provider Name (Legal Business Name) : EVERGREEN PEDIATRIC THERAPY LLC
Provider Business Mailing Address
First Line : 3500 W EVERGREEN AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60651
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1803 N CALIFORNIA AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60647-5105
Country : US
Telephone Number : 217-549-4507
Fax Number :
Authorized Official
Title or Position : OWNER/SPEECH-LANGUAGE PATHOLOGIST
Name : LEAH SONGER
Credential : M.A., CCC-SLP
Telephone Number : 217-549-4507
Provider Enumeration Date : 01/08/2018
Last Update Date : 01/08/2018

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Directions to “EVERGREEN PEDIATRIC THERAPY LLC ” Practice Location

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