=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124594551
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE CENTRE OF INFINITE POSSIBILITIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2018
-----------------------------------------------------
Last Update Date | 10/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2324 W JACKSON BLVD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-2913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-230-2304
-----------------------------------------------------
Fax | 888-974-1473
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7723
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60680-7723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-230-2304
-----------------------------------------------------
Fax | 888-974-1473
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DEVELOPMENTAL THERAPIST/PARENT EDUC
-----------------------------------------------------
Name | COLETTE GATLING-MARTIN
-----------------------------------------------------
Credential | M.S.
-----------------------------------------------------
Telephone | 773-230-2304
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 222Q00000X
-----------------------------------------------------
Taxonomy Name | Developmental Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------