MEDICARE: FUNDAMENTALS PEDIATRIC THERAPY AND CONSULTING 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	:	1922473008
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNDAMENTALS PEDIATRIC THERAPY AND CONSULTING INC.

Provider Business Mailing Address
First Line	:	215 S SPRINGSIDE DR
Second Line	:
City	:	ROUND LAKE BEACH
State	:	IL
Zip	:	60073-8139
Country	:	US
Telephone Number	:	847-477-9816
Fax Number	:	847-574-8147

Provider Business Practice Location Address
First Line	:	215 S SPRINGSIDE DR
Second Line	:
City	:	ROUND LAKE BEACH
State	:	IL
Zip	:	60073-8139
Country	:	US
Telephone Number	:	847-477-9816
Fax Number	:	847-574-8147

Authorized Official
Title or Position	:	THERAPIST
Name	:	MS. KIRSTEN ELISE RYAN
Credential	:	MA LCPC
Telephone Number	:	847-477-9816

Provider Enumeration Date	:	12/01/2015
Last Update Date	:	12/01/2015

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