Provider Demographics
NPI:1104959998
Name:PEDIATRIC PHYSICAL THERAPY OF CENTRAL ILLINOIS LTD
Entity type:Organization
Organization Name:PEDIATRIC PHYSICAL THERAPY OF CENTRAL ILLINOIS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:217-840-3915
Mailing Address - Street 1:PO BOX 211
Mailing Address - Street 2:123 W WILLIAM STREET
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856
Mailing Address - Country:US
Mailing Address - Phone:217-840-3915
Mailing Address - Fax:
Practice Address - Street 1:123 W WILLIAM STREET
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856
Practice Address - Country:US
Practice Address - Phone:217-840-3915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty