Provider Demographics
NPI:1922033083
Name:INTEGRATED THERAPY PRACTICE, PC
Entity Type:Organization
Organization Name:INTEGRATED THERAPY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SILLEVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:219-531-1756
Mailing Address - Street 1:1265 S LAKE PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-5961
Mailing Address - Country:US
Mailing Address - Phone:219-531-1756
Mailing Address - Fax:219-531-1759
Practice Address - Street 1:1265 S LAKE PARK AVE
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-5961
Practice Address - Country:US
Practice Address - Phone:219-531-1756
Practice Address - Fax:219-531-1759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000372620OtherANTHEM
IN200346180Medicaid
FLY90R3OtherBCBS FLORIDA
IL90001194OtherBC/BS
FLGE029AMedicare PIN
INDD7079Medicare PIN
IN000000372620OtherANTHEM
IL90001194OtherBC/BS
FLY90R3OtherBCBS FLORIDA
IN5287440003Medicare NSC