Healthcare Provider Details

I. General information

NPI: 1487951018
Provider Name (Legal Business Name): ELAINE BUCHANAN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2011
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VETERANS DR
MANTENO IL
60950-9466
US

IV. Provider business mailing address

6550 S NORMAL BLVD FL 1
CHICAGO IL
60621-2633
US

V. Phone/Fax

Practice location:
  • Phone: 815-468-6581
  • Fax:
Mailing address:
  • Phone: 773-971-7744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number208.000123
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06003842A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA0990
License Number StateNV
# 4
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160004968
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: