Healthcare Provider Details

I. General information

NPI: 1376002980
Provider Name (Legal Business Name): CYNTHIA BROWN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CYNTHIA RICHTER

II. Dates (important events)

Enumeration Date: 03/14/2019
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 DEKALB AVE
SYCAMORE IL
60178-2703
US

IV. Provider business mailing address

1952 ABERDEEN CT
SYCAMORE IL
60178-3175
US

V. Phone/Fax

Practice location:
  • Phone: 815-758-0000
  • Fax:
Mailing address:
  • Phone: 815-991-2333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160006997
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: