Provider Demographics
NPI:1588472237
Name:POPPY CHILDRENS THERAPY
Entity type:Organization
Organization Name:POPPY CHILDRENS THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAYNE
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:MHS, CCC-SLP
Authorized Official - Phone:989-992-7918
Mailing Address - Street 1:1308 NEW CASTLE DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5307
Mailing Address - Country:US
Mailing Address - Phone:989-992-7918
Mailing Address - Fax:
Practice Address - Street 1:1308 NEW CASTLE DR
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5307
Practice Address - Country:US
Practice Address - Phone:989-992-7918
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-27
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1184074296Medicaid