Healthcare Provider Details

I. General information

NPI: 1306263124
Provider Name (Legal Business Name): PAMELA WOOD PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2014
Last Update Date: 03/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 GRANT ST
HARVARD IL
60033-1821
US

IV. Provider business mailing address

901 GRANT ST
HARVARD IL
60033-1821
US

V. Phone/Fax

Practice location:
  • Phone: 815-943-5431
  • Fax: 815-943-0659
Mailing address:
  • Phone: 815-943-5431
  • Fax: 815-943-0659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160-006461
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: