Healthcare Provider Details

I. General information

NPI: 1437082054
Provider Name (Legal Business Name): LISA VACCARELLO PTA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 S MICHIGAN AVE
CHICAGO IL
60616-1713
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 312-284-1100
  • Fax: 312-284-1104
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.010639
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: