Healthcare Provider Details

I. General information

NPI: 1447548557
Provider Name (Legal Business Name): FUNDAMENTAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 07/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3721 N RICHMOND ST
CHICAGO IL
60618-3524
US

IV. Provider business mailing address

3721 N. RICHMOND
CHICAGO IL
60618
US

V. Phone/Fax

Practice location:
  • Phone: 773-991-9953
  • Fax: 773-478-9245
Mailing address:
  • Phone: 773-991-9953
  • Fax: 773-478-9245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number070012672
License Number StateIL

VIII. Authorized Official

Name: KARA BOYNEWICZ
Title or Position: OWNER
Credential: PT
Phone: 773-991-9953