Healthcare Provider Details

I. General information

NPI: 1003356817
Provider Name (Legal Business Name): INNOVATIONS PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2017
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 YOUNT DR
BLOOMINGTON IL
61704-3745
US

IV. Provider business mailing address

212 EDWARDS DR
NORMAL IL
61761-2334
US

V. Phone/Fax

Practice location:
  • Phone: 309-824-7417
  • Fax:
Mailing address:
  • Phone: 309-824-7417
  • Fax: 309-408-0255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056006902
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number056006902
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number056006902
License Number StateIL

VIII. Authorized Official

Name: REBECCA L GOLLADAY
Title or Position: OWNER
Credential: OTR/L
Phone: 309-824-7417