Healthcare Provider Details

I. General information

NPI: 1639310048
Provider Name (Legal Business Name): TINY BLOOMERS THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2009
Last Update Date: 04/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 BLUEJAY LN
PLAINFIELD IL
60586-2461
US

IV. Provider business mailing address

1204 BLUEJAY LN
PLAINFIELD IL
60586-2461
US

V. Phone/Fax

Practice location:
  • Phone: 773-838-9539
  • Fax: 815-254-0217
Mailing address:
  • Phone: 773-838-9539
  • Fax: 815-254-0217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MRS. MONICA HERRERA
Title or Position: DEVELOPMENTAL THERAPIST/OWNER
Credential: M.ED.
Phone: 773-383-9539