Provider Demographics
NPI:1356677462
Name:SOUTH LOOP PEDIATRIC THERAPY LLC
Entity Type:Organization
Organization Name:SOUTH LOOP PEDIATRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANA
Authorized Official - Middle Name:MARLENE
Authorized Official - Last Name:SUSIE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:773-733-1695
Mailing Address - Street 1:1515 S PRAIRIE AVE
Mailing Address - Street 2:UNIT 603
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3043
Mailing Address - Country:US
Mailing Address - Phone:773-733-1695
Mailing Address - Fax:773-435-6595
Practice Address - Street 1:1515 S PRAIRIE AVE
Practice Address - Street 2:UNIT 603
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3043
Practice Address - Country:US
Practice Address - Phone:773-733-1695
Practice Address - Fax:773-435-6595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-23
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.0135582251P0200X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Single Specialty