Provider Demographics
NPI:1265530281
Name:SUCCESSFUL KIDS
Entity type:Organization
Organization Name:SUCCESSFUL KIDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BRAATEN-HEIDENREICH
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:815-685-4608
Mailing Address - Street 1:12115 S WOLF DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-9755
Mailing Address - Country:US
Mailing Address - Phone:815-685-4608
Mailing Address - Fax:
Practice Address - Street 1:12115 S WOLF DR
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-9755
Practice Address - Country:US
Practice Address - Phone:815-685-4608
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09932463Medicare UPIN