Healthcare Provider Details

I. General information

NPI: 1215462130
Provider Name (Legal Business Name): ALI N GRAHAM DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2017
Last Update Date: 10/14/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 N MICHIGAN AVE LBBY 103
CHICAGO IL
60602-4817
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 312-236-0660
  • Fax: 312-236-1219
Mailing address:
  • Phone: 630-575-1980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-025436
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: