1922473008 NPI number — FUNDAMENTALS PEDIATRIC THERAPY AND CONSULTING INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922473008 NPI number — FUNDAMENTALS PEDIATRIC THERAPY AND CONSULTING INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FUNDAMENTALS PEDIATRIC THERAPY AND CONSULTING INC.
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:
1922473008
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 S SPRINGSIDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROUND LAKE BEACH
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60073-8139
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-477-9816
Provider Business Mailing Address Fax Number:
847-574-8147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 S SPRINGSIDE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROUND LAKE BEACH
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60073-8139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-477-9816
Provider Business Practice Location Address Fax Number:
847-574-8147
Provider Enumeration Date:
12/01/2015

Additional Information

Authorized Official

Authorized Official Last Name:
RYAN
Authorized Official First Name:
KIRSTEN
Authorized Official Middle Name:
ELISE
Authorized Official Title or Position:
THERAPIST
Authorized Official Telephone Number:
847-477-9816

Provider Taxonomy Codes

  • Taxonomy code: 252Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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