Healthcare Provider Details

I. General information

NPI: 1669597332
Provider Name (Legal Business Name): DAISY TAN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 DEMPSTER ST FL 3
PARK RIDGE IL
60068-1110
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 847-318-9330
  • Fax: 847-723-9441
Mailing address:
  • Phone: 847-390-5900
  • Fax: 847-390-5450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number070-012750
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: