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General NPI Number Information
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NPI Number | 1134905482
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Entity Type | Organization
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Legal Business Name | CLEMENTINE PEDIATRICS, LLC
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Dates
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Enumeration Date | 09/04/2023
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Last Update Date | 10/01/2025
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Provider Practice Location Address
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Address Line | 1757 N KIMBALL AVE STE 205A
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City | CHICAGO
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State | IL
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Zip | 60647-4805
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Country | US
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Telephone | 816-914-0359
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Fax |
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Provider Business Mailing Address
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Address Line | 1757 N KIMBALL AVE STE 205A
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City | CHICAGO
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State | IL
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Zip | 60647-4805
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Country | US
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Telephone | 816-914-0359
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SARA P VIVODA
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Credential | MOT, OTR/L, CLC
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Telephone | 816-914-0359
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XF0002X
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Taxonomy Name | Feeding, Eating & Swallowing Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 174N00000X
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Taxonomy Name | Lactation Consultant (Non-RN)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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