Healthcare Provider Details

I. General information

NPI: 1356562409
Provider Name (Legal Business Name): I THINK I CAN LEARNING CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 N RUBY LN
FAIRVIEW HEIGHTS IL
62208-1926
US

IV. Provider business mailing address

125 N RUBY LN
FAIRVIEW HEIGHTS IL
62208-1926
US

V. Phone/Fax

Practice location:
  • Phone: 618-398-4226
  • Fax: 618-398-1759
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier145960
Identifier TypeOTHER
Identifier StateMO
Identifier IssuerBCBS MO
# 2
Identifier8220492
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBCBS IL

VIII. Authorized Official

Name: LISA GRYBINAS
Title or Position: OWNER
Credential:
Phone: 618-398-4226