Healthcare Provider Details

I. General information

NPI: 1992963813
Provider Name (Legal Business Name): KIDWORKS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 S CALUMET RD STE 3
CHESTERTON IN
46304-3286
US

IV. Provider business mailing address

1120 S CALUMET RD STE 3
CHESTERTON IN
46304-3286
US

V. Phone/Fax

Practice location:
  • Phone: 219-983-9675
  • Fax: 219-983-9675
Mailing address:
  • Phone: 219-983-9675
  • Fax: 219-983-9675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05008714A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number46001702A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31003944A
License Number StateIN

VIII. Authorized Official

Name: MR. CYNTHIA SUZANNE MANGAN
Title or Position: CO-OWNER
Credential:
Phone: 219-983-9675