Provider Demographics
NPI:1184744625
Name:INDEPENDENCE HEALTH & THERAPY
Entity type:Organization
Organization Name:INDEPENDENCE HEALTH & THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:815-333-8657
Mailing Address - Street 1:2028 N. SEMINARY AVE.
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098
Mailing Address - Country:US
Mailing Address - Phone:815-338-3590
Mailing Address - Fax:815-337-4406
Practice Address - Street 1:708 WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098
Practice Address - Country:US
Practice Address - Phone:815-338-1707
Practice Address - Fax:815-338-1786
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDEPENDENCE HEALTH & THERAPY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-29
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225XP0200X, 235Z00000X, 251K00000X
IL1747736251K00000X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251K00000XAgenciesPublic Health or Welfare
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362264411001Medicaid
IL05615103OtherBLUE CROSS BLUE SHIELD
IL146712Medicare Oscar/Certification