Provider Demographics
NPI:1700067139
Name:ACORN PEDIATRIC THERAPY LLC
Entity Type:Organization
Organization Name:ACORN PEDIATRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST/ MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMI
Authorized Official - Middle Name:
Authorized Official - Last Name:GANDHI
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:847-571-4649
Mailing Address - Street 1:824 S MAIN ST
Mailing Address - Street 2:STE 104
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-6265
Mailing Address - Country:US
Mailing Address - Phone:847-571-4649
Mailing Address - Fax:815-788-0087
Practice Address - Street 1:824 S MAIN ST
Practice Address - Street 2:STE 104
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6265
Practice Address - Country:US
Practice Address - Phone:847-571-4649
Practice Address - Fax:815-788-0087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056005208225X00000X
IL146000425235Z00000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty