Healthcare Provider Details

I. General information

NPI: 1326447061
Provider Name (Legal Business Name): JANET MOFFAT LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 05/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 VICTORIA ST
ANTIOCH IL
60002-1519
US

IV. Provider business mailing address

960 VICTORIA ST
ANTIOCH IL
60002-1519
US

V. Phone/Fax

Practice location:
  • Phone: 847-838-0688
  • Fax: 847-838-0690
Mailing address:
  • Phone: 847-838-0688
  • Fax: 847-838-0690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227.014949
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: