Healthcare Provider Details

I. General information

NPI: 1356712624
Provider Name (Legal Business Name): PLAY WELL PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2015
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 DALLAS RD
WASHINGTON IL
61571-9230
US

IV. Provider business mailing address

804 DALLAS RD
WASHINGTON IL
61571-9230
US

V. Phone/Fax

Practice location:
  • Phone: 309-846-6664
  • Fax:
Mailing address:
  • Phone: 309-846-6664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number056.009667
License Number StateIL

VIII. Authorized Official

Name: MRS. KIMBERLY KAY PETERSON
Title or Position: PEDIATRIC OCCUPATIONAL THERAPIST
Credential: MOT, OTR/L
Phone: 309-846-6664