Healthcare Provider Details

I. General information

NPI: 1740653328
Provider Name (Legal Business Name): PENELOPE P PEREZ PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2015
Last Update Date: 09/24/2021
Certification Date: 09/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3544 S 57TH AVE
CICERO IL
60804-4345
US

IV. Provider business mailing address

3544 S 57TH AVE
CICERO IL
60804-4345
US

V. Phone/Fax

Practice location:
  • Phone: 708-415-1916
  • Fax:
Mailing address:
  • Phone: 708-415-1916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.026266
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.006416
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: