Healthcare Provider Details

I. General information

NPI: 1851950414
Provider Name (Legal Business Name): HERBOTH DEVELOPMENTAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2868 E 825TH AVE
ALTAMONT IL
62411-3554
US

IV. Provider business mailing address

2868 E 825TH AVE
ALTAMONT IL
62411-3554
US

V. Phone/Fax

Practice location:
  • Phone: 618-322-5493
  • Fax: 217-280-4261
Mailing address:
  • Phone: 618-322-5493
  • Fax: 217-280-4261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: SHELLY HERBOTH
Title or Position: OWNER
Credential:
Phone: 618-322-5493