Healthcare Provider Details

I. General information

NPI: 1962174631
Provider Name (Legal Business Name): SPECIALIZED PT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 07/10/2022
Certification Date: 07/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 N RACINE AVE UNIT 1000B
CHICAGO IL
60614-4045
US

IV. Provider business mailing address

3838 N HAMILTON AVE
CHICAGO IL
60618-3918
US

V. Phone/Fax

Practice location:
  • Phone: 773-835-1884
  • Fax:
Mailing address:
  • Phone: 773-835-1884
  • Fax: 773-672-7618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. MAUREEN MCCLAIN GEORGE
Title or Position: PRESIDENT
Credential: PT
Phone: 773-835-1884