Provider Demographics
| NPI: | 1568460681 |
|---|---|
| Name: | EASTER SEALS DUPAGE AND THE FOX VALLEY REGION |
| Entity Type: | Organization |
| Organization Name: | EASTER SEALS DUPAGE AND THE FOX VALLEY REGION |
| Other - Org Name: | EASTER SEALS DUPAGE |
| Other - Org Type: | Other Name |
| Authorized Official - Title/Position: | PRESIDENT/CEO |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | THERESA |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | FORTHOFER |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 630-620-4433 |
| Mailing Address - Street 1: | 830 S. ADDISON AVENUE |
| Mailing Address - Street 2: | |
| Mailing Address - City: | VILLA PARK |
| Mailing Address - State: | IL |
| Mailing Address - Zip Code: | 60181-2877 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 630-620-4433 |
| Mailing Address - Fax: | 630-620-1148 |
| Practice Address - Street 1: | 830 S. ADDISON AVENUE |
| Practice Address - Street 2: | |
| Practice Address - City: | VILLA PARK |
| Practice Address - State: | IL |
| Practice Address - Zip Code: | 60181 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 630-620-4433 |
| Practice Address - Fax: | 630-620-1148 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2005-07-12 |
| Last Update Date: | 2023-02-21 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
| No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | Group - Multi-Specialty |
| No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 133N00000X | Dietary & Nutritional Service Providers | Nutritionist | Group - Multi-Specialty | |
| No | 133V00000X | Dietary & Nutritional Service Providers | Dietitian, Registered | Group - Multi-Specialty | |
| No | 2080P0006X | Allopathic & Osteopathic Physicians | Pediatrics | Developmental - Behavioral Pediatrics | Group - Multi-Specialty |
| No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
| No | 222Q00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist | Group - Multi-Specialty | |
| No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
| No | 231H00000X | Speech, Language and Hearing Service Providers | Audiologist | Group - Multi-Specialty | |
| No | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Multi-Specialty | |
| No | 261QA3000X | Ambulatory Health Care Facilities | Clinic/Center | Augmentative Communication | |
| No | 261QD1600X | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | Group - Multi-Specialty |
| No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| IL | 02215165 | Other | BLUE CROSS BLUE SHIELD GROUP |
| IL | 02215165 | Other | BLUE CROSS BLUE SHIELD GROUP |
| IL | 6355670001 | Medicare NSC | |
| IL | 02215165 | Other | BLUE CROSS BLUE SHIELD GROUP |
| IL | 211862 | Medicare PIN |
