Provider Demographics
NPI:1275199150
Name:MARIGOLD PEDIATRIC THERAPY SERVICES LLC
Entity Type:Organization
Organization Name:MARIGOLD PEDIATRIC THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SLP
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-325-9513
Mailing Address - Street 1:121 POMEROY AVE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-5922
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 POMEROY AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-5922
Practice Address - Country:US
Practice Address - Phone:815-325-9513
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-15
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech