Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 070003612 | IL |
NPI | 1003216383 |
---|---|
Provider Name | Terri Roberts |
First Address | Oak Brook, IL 60523-1262 |
Second Address | Oak Brook, IL 60523-1262 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/08/2014 |
Last Update Date | 24/08/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
070003612 | PHYSICAL THERAPY LICENSE (01) | IL |