Provider Demographics
NPI:1588673602
Name:CHILDHOOD POTENTIALS INC.
Entity Type:Organization
Organization Name:CHILDHOOD POTENTIALS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST, PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:MHS, CCC-SLP/L
Authorized Official - Phone:815-370-4812
Mailing Address - Street 1:101 OLD FARM MIDDLE CT
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-1485
Mailing Address - Country:US
Mailing Address - Phone:815-932-4812
Mailing Address - Fax:815-936-9077
Practice Address - Street 1:101 OLD FARM MIDDLE CT
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-1485
Practice Address - Country:US
Practice Address - Phone:815-932-4812
Practice Address - Fax:815-936-9077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4632010OtherBCBS