Healthcare Provider Details

I. General information

NPI: 1740625797
Provider Name (Legal Business Name): JOANNA LYN TABUENA GALIAS PT, GCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2013
Last Update Date: 05/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 W MADISON ST APARTMENT 2905
CHICAGO IL
60661-2515
US

IV. Provider business mailing address

575 W MADISON ST APARTMENT 2905
CHICAGO IL
60661-2515
US

V. Phone/Fax

Practice location:
  • Phone: 217-592-6815
  • Fax:
Mailing address:
  • Phone: 217-592-6815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number070.016103
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: