Healthcare Provider Details

I. General information

NPI: 1306196753
Provider Name (Legal Business Name): MEG ANNE FENSHOLT PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W JEFFERSON AVE
WHEATON IL
60187-4111
US

IV. Provider business mailing address

220 W JEFFERSON AVE
WHEATON IL
60187-4111
US

V. Phone/Fax

Practice location:
  • Phone: 630-690-3315
  • Fax:
Mailing address:
  • Phone: 630-690-3315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.005752
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: