Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | 070-012852 | IL |
NPI | 1063438703 |
---|---|
Provider Name | Mrs. Julie Ann Wattenberg |
First Address | Plainfield, IL 60544-7563 |
Second Address | Plainfield, IL 60544-7563 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2006 |
Last Update Date | 25/04/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
02232772 | BLUE CROSS BLUE SHIELD (01) | IL |