=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467699827
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SONIA SHANKMAN ORTHOGENIC SCHOOL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2009
-----------------------------------------------------
Last Update Date | 01/07/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1365 E 60TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60637-2856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-702-1203
-----------------------------------------------------
Fax | 773-702-1304
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1365 E 60TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60637-2856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-702-1203
-----------------------------------------------------
Fax | 773-702-1304
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | DR. PETER G MYERS
-----------------------------------------------------
Credential | PSY D
-----------------------------------------------------
Telephone | 773-702-1301
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 5734-613-2
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------