Provider Demographics
NPI:1972869550
Name:PLATINUM PEDIATRIC THERAPY, INC.
Entity Type:Organization
Organization Name:PLATINUM PEDIATRIC THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ SLP
Authorized Official - Prefix:MS
Authorized Official - First Name:LORA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOZELL
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:815-505-4463
Mailing Address - Street 1:12937 BLUE SPRUCE DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-2979
Mailing Address - Country:US
Mailing Address - Phone:815-505-4463
Mailing Address - Fax:
Practice Address - Street 1:12937 BLUE SPRUCE DR
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-2979
Practice Address - Country:US
Practice Address - Phone:815-505-4463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-08
Last Update Date:2012-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.005242252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency