Provider Demographics
NPI:1922473008
Name:FUNDAMENTALS PEDIATRIC THERAPY AND CONSULTING INC.
Entity Type:Organization
Organization Name:FUNDAMENTALS PEDIATRIC THERAPY AND CONSULTING INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:ELISE
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA LCPC
Authorized Official - Phone:847-477-9816
Mailing Address - Street 1:215 S SPRINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE BEACH
Mailing Address - State:IL
Mailing Address - Zip Code:60073-8139
Mailing Address - Country:US
Mailing Address - Phone:847-477-9816
Mailing Address - Fax:847-574-8147
Practice Address - Street 1:215 S SPRINGSIDE DR
Practice Address - Street 2:
Practice Address - City:ROUND LAKE BEACH
Practice Address - State:IL
Practice Address - Zip Code:60073-8139
Practice Address - Country:US
Practice Address - Phone:847-477-9816
Practice Address - Fax:847-574-8147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency