Provider Demographics
NPI:1265617583
Name:WYANT PEDIATRIC THERAPY SERVICES, INC.
Entity type:Organization
Organization Name:WYANT PEDIATRIC THERAPY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:KATHRYN
Authorized Official - Last Name:WYANT
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:847-975-5508
Mailing Address - Street 1:734 N HORIZON CT
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-7868
Mailing Address - Country:US
Mailing Address - Phone:847-975-5508
Mailing Address - Fax:847-265-4523
Practice Address - Street 1:734 N HORIZON CT
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-7868
Practice Address - Country:US
Practice Address - Phone:847-975-5508
Practice Address - Fax:847-265-4523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-05
Last Update Date:2008-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty