Healthcare Provider Details

I. General information

NPI: 1801062153
Provider Name (Legal Business Name): GINA M MUELLER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3703 W LAKE AVE SUITE200
GLENVIEW IL
60026-5823
US

IV. Provider business mailing address

3703 WEST LAKE AVE SUITE200
GLENVIWE IL
60026-1223
US

V. Phone/Fax

Practice location:
  • Phone: 847-998-1188
  • Fax:
Mailing address:
  • Phone: 847-998-1188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160001079
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: