Healthcare Provider Details

I. General information

NPI: 1891387403
Provider Name (Legal Business Name): INCHWORMS PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2021
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 W DIVERSEY PKWY APT 1
CHICAGO IL
60614-6764
US

IV. Provider business mailing address

1350 W DIVERSEY PKWY APT 1
CHICAGO IL
60614-6764
US

V. Phone/Fax

Practice location:
  • Phone: 651-587-5454
  • Fax:
Mailing address:
  • Phone: 651-587-5454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINE GIFFHORN
Title or Position: PEDIATRIC PHYSICAL THERAPIST/OWNER
Credential: PT, DPT
Phone: 651-587-5454