Provider Demographics
NPI:1760863476
Name:PEDIATRIC THERAPY OF ILLINOIS LLC
Entity Type:Organization
Organization Name:PEDIATRIC THERAPY OF ILLINOIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEJONG
Authorized Official - Suffix:
Authorized Official - Credentials:DT
Authorized Official - Phone:630-415-6850
Mailing Address - Street 1:325 N LARCH AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2311
Mailing Address - Country:US
Mailing Address - Phone:630-415-6850
Mailing Address - Fax:630-359-4714
Practice Address - Street 1:325 N LARCH AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2311
Practice Address - Country:US
Practice Address - Phone:630-415-6850
Practice Address - Fax:630-359-4714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty