Provider Demographics
NPI:1740625425
Name:GERIATRIC THERAPY SPECIALIST, INC
Entity type:Organization
Organization Name:GERIATRIC THERAPY SPECIALIST, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:
Authorized Official - First Name:ALLYSON
Authorized Official - Middle Name:
Authorized Official - Last Name:BLASIUS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:773-960-7919
Mailing Address - Street 1:133 N HUMPHREY AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:133 N HUMPHREY AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2513
Practice Address - Country:US
Practice Address - Phone:774-960-7919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.013000305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service