Provider Demographics
NPI:1992963813
Name:KIDWORKS
Entity type:Organization
Organization Name:KIDWORKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:MANGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-983-9675
Mailing Address - Street 1:1120 S CALUMET RD STE 3
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-3286
Mailing Address - Country:US
Mailing Address - Phone:219-983-9675
Mailing Address - Fax:219-983-9675
Practice Address - Street 1:1120 S CALUMET RD STE 3
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-3286
Practice Address - Country:US
Practice Address - Phone:219-983-9675
Practice Address - Fax:219-983-9675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008714A225100000X
IN31003944A225X00000X
IN46001702A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200861720AMedicaid
IN200837200AOtherMEDICAID FIRST STEPS GROUP #