Provider Demographics
NPI:1639565864
Name:ABC DEVELOPMENTAL PLAY, LTD
Entity Type:Organization
Organization Name:ABC DEVELOPMENTAL PLAY, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANASTASIA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:VITHOULKAS
Authorized Official - Suffix:
Authorized Official - Credentials:DT,CHILD SP, SP ED
Authorized Official - Phone:708-261-5786
Mailing Address - Street 1:18236 CLEAR CREEK XING
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-5237
Mailing Address - Country:US
Mailing Address - Phone:708-261-5786
Mailing Address - Fax:708-478-6773
Practice Address - Street 1:1500 RAVINIA PL
Practice Address - Street 2:1E
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3962
Practice Address - Country:US
Practice Address - Phone:708-261-5786
Practice Address - Fax:708-478-6773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILAV42821006P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty