Healthcare Provider Details

I. General information

NPI: 1760546402
Provider Name (Legal Business Name): ANGELA L AUSILI P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2338 W SUD PKWY STE 3100
PEORIA IL
61615-7482
US

IV. Provider business mailing address

2338 W SUD PKWY STE 3100
PEORIA IL
61615-7482
US

V. Phone/Fax

Practice location:
  • Phone: 309-693-9189
  • Fax: 309-693-9946
Mailing address:
  • Phone: 309-693-9189
  • Fax: 309-693-9946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-015408
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: