Provider Demographics
NPI:1235646894
Name:IMAGINATION THERAPY, LLC
Entity Type:Organization
Organization Name:IMAGINATION THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH PATHOLOGIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILKIE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:708-305-2176
Mailing Address - Street 1:805 LAKE ST # 235
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:805 LAKE ST # 235
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1301
Practice Address - Country:US
Practice Address - Phone:708-305-2176
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.011712235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1154756443Medicaid