Healthcare Provider Details

I. General information

NPI: 1629226188
Provider Name (Legal Business Name): GWEN D WEIDELL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2008
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 E SUPERIOR ST
CHICAGO IL
60611-2654
US

IV. Provider business mailing address

7411 N SEELEY AVE UNIT 1C
CHICAGO IL
60645-2261
US

V. Phone/Fax

Practice location:
  • Phone: 312-238-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160002290
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: