Healthcare Provider Details

I. General information

NPI: 1972869550
Provider Name (Legal Business Name): PLATINUM PEDIATRIC THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2012
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12937 BLUE SPRUCE DR
PLAINFIELD IL
60585-2979
US

IV. Provider business mailing address

12937 BLUE SPRUCE DR
PLAINFIELD IL
60585-2979
US

V. Phone/Fax

Practice location:
  • Phone: 815-505-4463
  • Fax:
Mailing address:
  • Phone: 815-505-4463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number146.005242
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
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: MS. LORA CAMPBELL
Title or Position: PRESIDENT/ SLP
Credential: MS CCC-SLP
Phone: 815-505-4463