Healthcare Provider Details

I. General information

NPI: 1811191075
Provider Name (Legal Business Name): MICHELLE MARIE URBAN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 N OAK PARK AVE
CHICAGO IL
60707-3351
US

IV. Provider business mailing address

631 NEWCASTLE AVE
WESTCHESTER IL
60154-2630
US

V. Phone/Fax

Practice location:
  • Phone: 773-385-5574
  • Fax: 773-385-5851
Mailing address:
  • Phone: 708-297-5926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number070007070
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: