Basic Information
Provider Information | |||||||||
NPI: | 1972783900 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WESTSIDE CHILDRENS THERAPY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1419 ESSINGTON RD | ||||||||
Address2: |   | ||||||||
City: | JOLIET | ||||||||
State: | IL | ||||||||
PostalCode: | 604352873 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8157292160 | ||||||||
FaxNumber: | 8157292958 | ||||||||
Practice Location | |||||||||
Address1: | 1419 ESSINGTON RD | ||||||||
Address2: |   | ||||||||
City: | JOLIET | ||||||||
State: | IL | ||||||||
PostalCode: | 604352873 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 1815729216 | ||||||||
FaxNumber: | 8157292958 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/07/2007 | ||||||||
LastUpdateDate: | 10/14/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CASSIDY | ||||||||
AuthorizedOfficialFirstName: | SHARI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/PHYSICAL THERAPIST | ||||||||
AuthorizedOfficialTelephone: | 18154741495 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 235Z00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 225100000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.