1891868063 NPI number — BRAVO PEDIATRIC THERAPIES

Table of content: LAURIE HOROWITZ HUMBERT PH.D. (NPI 1558850479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891868063 NPI number — BRAVO PEDIATRIC THERAPIES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRAVO PEDIATRIC THERAPIES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891868063
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1153 GUNDERSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60304-2150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-551-0004
Provider Business Mailing Address Fax Number:
773-305-8081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1153 GUNDERSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60304-2150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-551-0004
Provider Business Practice Location Address Fax Number:
733-305-8081
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SANCHEZ
Authorized Official First Name:
CLAUDETTE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT/SPEECH LANGUAGE PATHOLOGI
Authorized Official Telephone Number:
773-551-0004

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  146006271 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01636006 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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