Basic Information
| Provider Information | |||||||||
| NPI: | 1639211022 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH SHORE PEDIATRIC THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1308 WAUKEGAN RD | ||||||||
| Address2: | |||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600253070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474864140 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1308 WAUKEGAN RD | ||||||||
| Address2: | |||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600253070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474864140 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MICHAEL | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | FOUNDER AND OCCUPATIONAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 8474864140 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MS, OTR L | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251P0200X | 07015233 | IL | X | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | 225XP0200X | IL | X | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 225XP0200X | IL | X | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 01623839 | 01 | IL | BCBS NUMBER | OTHER |