Healthcare Provider Details

I. General information

NPI: 1134905482
Provider Name (Legal Business Name): CLEMENTINE PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2023
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1757 N KIMBALL AVE STE 205A
CHICAGO IL
60647-4805
US

IV. Provider business mailing address

1757 N KIMBALL AVE STE 205A
CHICAGO IL
60647-4805
US

V. Phone/Fax

Practice location:
  • Phone: 816-914-0359
  • Fax:
Mailing address:
  • Phone: 816-914-0359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: SARA P VIVODA
Title or Position: OWNER
Credential: MOT, OTR/L, CLC
Phone: 816-914-0359