Healthcare Provider Details

I. General information

NPI: 1124044698
Provider Name (Legal Business Name): ABC PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 06/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

634 N MAIN ST SUITE 3
O FALLON IL
62269-3746
US

IV. Provider business mailing address

634 N MAIN ST SUITE 3
O FALLON IL
62269-3746
US

V. Phone/Fax

Practice location:
  • Phone: 618-632-4222
  • Fax: 618-632-4658
Mailing address:
  • Phone: 618-632-4222
  • Fax: 618-632-4658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: AMY L. BRUCE
Title or Position: OWNER
Credential: MS CCC-SLP
Phone: 618-632-4222