Organization
ABC PEDIATRIC THERAPY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
AMY L. BRUCE MS CCC-SLP (OWNER)
(618) 632-4222
Entity
Organization
Contact information
Practice address
634 N MAIN ST, SUITE 3, O FALLON, IL 62269-3746
(618) 632-4222
(618) 632-4658
Mailing address
634 N MAIN ST, SUITE 3, O FALLON, IL 62269-3746
(618) 632-4222
(618) 632-4658
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
—
—
225X00000X
Occupational Therapist
—
—
235Z00000X
Speech-Language Pathologist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
08232136
BLUE CROSS BLUE SHIELD
IL
05
—
348620164001
—
IL
Enumeration date
07/15/2006
Last updated
06/17/2011
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