=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356677462
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH LOOP PEDIATRIC THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2009
-----------------------------------------------------
Last Update Date | 10/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 S PRAIRIE AVE UNIT 603
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60605-3043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-733-1695
-----------------------------------------------------
Fax | 773-435-6595
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 S PRAIRIE AVE UNIT 603
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60605-3043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-733-1695
-----------------------------------------------------
Fax | 773-435-6595
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | MRS. JANA MARLENE SUSIE
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 773-733-1695
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 070.013558
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number | 070.013558
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------