Provider Demographics
NPI:1467538173
Name:PEDIATRIC THERAPY SERVICES OF MACOMB, LLC
Entity Type:Organization
Organization Name:PEDIATRIC THERAPY SERVICES OF MACOMB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:309-836-3456
Mailing Address - Street 1:PO BOX 311
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-0311
Mailing Address - Country:US
Mailing Address - Phone:309-836-3456
Mailing Address - Fax:309-836-5678
Practice Address - Street 1:130 N SIDE SQ
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-2214
Practice Address - Country:US
Practice Address - Phone:309-836-3456
Practice Address - Fax:309-836-5678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty