Healthcare Provider Details

I. General information

NPI: 1902319916
Provider Name (Legal Business Name): MARVELOUS MINDS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2017
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 PENNSYLVANIA AVE STE 101
GLEN ELLYN IL
60137-4427
US

IV. Provider business mailing address

420 PENNSYLVANIA AVE STE 101
GLEN ELLYN IL
60137-4427
US

V. Phone/Fax

Practice location:
  • Phone: 630-474-4353
  • Fax: 630-790-8898
Mailing address:
  • Phone: 630-474-4353
  • Fax: 630-790-8898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: DR. KYMBERLY FAY LARSON
Title or Position: PRESIDENT
Credential: PSYD
Phone: 630-474-4353