Healthcare Provider Details

I. General information

NPI: 1356677462
Provider Name (Legal Business Name): SOUTH LOOP PEDIATRIC THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2009
Last Update Date: 10/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 S PRAIRIE AVE UNIT 603
CHICAGO IL
60605-3043
US

IV. Provider business mailing address

1515 S PRAIRIE AVE UNIT 603
CHICAGO IL
60605-3043
US

V. Phone/Fax

Practice location:
  • Phone: 773-733-1695
  • Fax: 773-435-6595
Mailing address:
  • Phone: 773-733-1695
  • Fax: 773-435-6595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number070.013558
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number070.013558
License Number StateIL

VIII. Authorized Official

Name: MRS. JANA MARLENE SUSIE
Title or Position: PHYSICAL THERAPIST
Credential: P.T.
Phone: 773-733-1695