Healthcare Provider Details

I. General information

NPI: 1629211362
Provider Name (Legal Business Name): FUNCTIONAL THERAPY SPECIALISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2009
Last Update Date: 04/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N YORK RD SUITE 4
ELMHURST IL
60126-5510
US

IV. Provider business mailing address

401 N YORK RD SUITE 4
ELMHURST IL
60126-5510
US

V. Phone/Fax

Practice location:
  • Phone: 630-941-8190
  • Fax: 630-941-8194
Mailing address:
  • Phone: 630-941-8190
  • Fax: 630-941-8194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070014040
License Number StateIL

VIII. Authorized Official

Name: DR. DOUG SIMPER
Title or Position: PRESIDENT
Credential: D.C.
Phone: 630-941-8190