Basic Information
| Provider Information | |||||||||
| NPI: | 1437359189 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH SHORE PEDIATRIC THERAPY | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1307 WAUKEGAN RD | ||||||||
| Address2: | |||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600253070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479422187 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1442 OLD SKOKIE RD | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600353032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474864140 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2007 | ||||||||
| LastUpdateDate: | 07/30/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MICHAEL | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OCCUPATIONAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 8474864140 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | OTR/L | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | Y | Managed Care Organizations | Preferred Provider Organization |
No ID Information.