Provider Demographics
NPI:1124044698
Name:ABC PEDIATRIC THERAPY, LLC
Entity Type:Organization
Organization Name:ABC PEDIATRIC THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:618-632-4222
Mailing Address - Street 1:634 N MAIN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-3746
Mailing Address - Country:US
Mailing Address - Phone:618-632-4222
Mailing Address - Fax:618-632-4658
Practice Address - Street 1:634 N MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-3746
Practice Address - Country:US
Practice Address - Phone:618-632-4222
Practice Address - Fax:618-632-4658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08232136OtherBLUE CROSS BLUE SHIELD
IL348620164001Medicaid