=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770011900
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PLAY WELL THERAPY SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9016 W 22ND PL
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60546-1021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-257-3472
-----------------------------------------------------
Fax | 888-965-6037
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9016 W 22ND PL
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60546-1021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-257-3472
-----------------------------------------------------
Fax | 888-965-6037
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DEVELOPMENTAL THERAPIST
-----------------------------------------------------
Name | NANCY M ROUDEBUSH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-257-3472
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------