Provider Demographics
NPI:1609439702
Name:MOTORVATION PEDIATRIC SERVICES
Entity Type:Organization
Organization Name:MOTORVATION PEDIATRIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LATESHA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:MOT OTR/L
Authorized Official - Phone:773-879-0436
Mailing Address - Street 1:12615 S ALPINE DR APT 6
Mailing Address - Street 2:
Mailing Address - City:ALSIP
Mailing Address - State:IL
Mailing Address - Zip Code:60803-3319
Mailing Address - Country:US
Mailing Address - Phone:773-879-0436
Mailing Address - Fax:
Practice Address - Street 1:12615 S ALPINE DR APT 6
Practice Address - Street 2:
Practice Address - City:ALSIP
Practice Address - State:IL
Practice Address - Zip Code:60803-3319
Practice Address - Country:US
Practice Address - Phone:773-879-0436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-15
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1578998167Medicaid