Healthcare Provider Details

I. General information

NPI: 1508622614
Provider Name (Legal Business Name): IMPACT PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 S STATE ST STE 300
CHICAGO IL
60605-2775
US

IV. Provider business mailing address

PO BOX 220
WESTMONT IL
60559-0220
US

V. Phone/Fax

Practice location:
  • Phone: 312-877-5101
  • Fax: 312-877-5906
Mailing address:
  • Phone: 708-590-6663
  • Fax: 709-469-4100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DENISE M DEASY
Title or Position: HR DIRECTOR
Credential:
Phone: 630-399-1015