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General NPI Number Information
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NPI Number | 1851950414
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Entity Type | Organization
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Legal Business Name | HERBOTH DEVELOPMENTAL THERAPY
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Dates
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Enumeration Date | 06/07/2019
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Last Update Date | 06/07/2019
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Provider Practice Location Address
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Address Line | 2868 E 825TH AVE
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City | ALTAMONT
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State | IL
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Zip | 62411-3554
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Country | US
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Telephone | 618-322-5493
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Fax | 217-280-4261
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Provider Business Mailing Address
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Address Line | 2868 E 825TH AVE
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City | ALTAMONT
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State | IL
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Zip | 62411-3554
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Country | US
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Telephone | 618-322-5493
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Fax | 217-280-4261
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Authorized Official
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Title or Position | OWNER
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Name | SHELLY HERBOTH
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Credential |
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Telephone | 618-322-5493
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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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 | 222Q00000X
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Taxonomy Name | Developmental Therapist
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License Number |
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License Number State |
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