Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 070.011041 | IL |
N | 2251X0800X | Physical Therapist - Orthopedic | 070.011041 | IL |
NPI | 1053635219 |
---|---|
Provider Name | Holly Eve Mandziara |
First Address | Des Plaines, IL 60016-4206 |
Second Address | Des Plaines, IL 60016-4206 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/03/2010 |
Last Update Date | 17/03/2010 |