Healthcare Provider Details

I. General information

NPI: 1265617583
Provider Name (Legal Business Name): WYANT PEDIATRIC THERAPY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2008
Last Update Date: 01/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

734 N HORIZON CT
LINDENHURST IL
60046-7868
US

IV. Provider business mailing address

734 N HORIZON CT
LINDENHURST IL
60046-7868
US

V. Phone/Fax

Practice location:
  • Phone: 847-975-5508
  • Fax: 847-265-4523
Mailing address:
  • Phone: 847-975-5508
  • Fax: 847-265-4523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateIL

VIII. Authorized Official

Name: JULIE KATHRYN WYANT
Title or Position: PRESIDENT
Credential: OTR/L
Phone: 847-975-5508