Provider Demographics
NPI:1891909594
Name:PEDIASOURCE THERAPY SPECIALISTS
Entity Type:Organization
Organization Name:PEDIASOURCE THERAPY SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEMA
Authorized Official - Middle Name:RAJ
Authorized Official - Last Name:TRUKENBROD
Authorized Official - Suffix:
Authorized Official - Credentials:OTRL
Authorized Official - Phone:773-988-9905
Mailing Address - Street 1:1872 N CLYBOURN AVE APT 111
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-4916
Mailing Address - Country:US
Mailing Address - Phone:773-988-9905
Mailing Address - Fax:773-404-1774
Practice Address - Street 1:2530 N LINCOLN AVE STE 114
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2479
Practice Address - Country:US
Practice Address - Phone:773-988-9905
Practice Address - Fax:773-404-1774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Not Answered2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
Not Answered225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty