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General NPI Number Information
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NPI Number | 1699192799
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Entity Type | Organization
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Legal Business Name | SKILL SPROUT
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Dates
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Enumeration Date | 03/26/2014
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Last Update Date | 03/26/2014
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Provider Practice Location Address
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Address Line | 97 EASTGATE DR
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City | WASHINGTON
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State | IL
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Zip | 61571-9271
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Country | US
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Telephone | 708-372-9684
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Fax |
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Provider Business Mailing Address
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Address Line | 524 CRESTVIEW DR
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City | METAMORA
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State | IL
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Zip | 61548-9660
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Country | US
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Telephone | 708-372-9684
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | KATIE LYNNE KLEIST
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Credential |
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Telephone | 708-372-9684
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 385HR2060X
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Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
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License Number | 178006427
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License Number State | IL
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