Healthcare Provider Details

I. General information

NPI: 1578777363
Provider Name (Legal Business Name): GINA M. TOTTEN L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3178 N BROADWAY ST
CHICAGO IL
60657-4509
US

IV. Provider business mailing address

3178 N BROADWAY ST
CHICAGO IL
60657-4509
US

V. Phone/Fax

Practice location:
  • Phone: 773-549-6400
  • Fax:
Mailing address:
  • Phone: 773-549-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227 007756
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: