Provider Demographics
NPI:1295404820
Name:ENGRAM
Entity Type:Organization
Organization Name:ENGRAM
Other - Org Name:ENGRAM THERAPY AND WELLNESS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARLA MAE
Authorized Official - Middle Name:R
Authorized Official - Last Name:HAVERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PT, GCS
Authorized Official - Phone:630-729-4344
Mailing Address - Street 1:2655 W PETERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-4017
Mailing Address - Country:US
Mailing Address - Phone:630-729-4344
Mailing Address - Fax:
Practice Address - Street 1:2655 W PETERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-4017
Practice Address - Country:US
Practice Address - Phone:630-729-4344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ENGRAM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-09-08
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1184899072Medicaid