Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 160006977 | IL |
NPI | 1013389998 |
---|---|
Provider Name | Sarah Teague |
First Address | Springfield, IL 62707-8596 |
Second Address | Springfield, IL 62707-8596 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/10/2015 |
Last Update Date | 30/10/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
160006977 | DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION (01) |