Healthcare Provider Details

I. General information

NPI: 1982201232
Provider Name (Legal Business Name): JENNA GRIVAS DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N 1ST ST
WHEELING IL
60090-2980
US

IV. Provider business mailing address

2 N OWEN ST
MT PROSPECT IL
60056-2532
US

V. Phone/Fax

Practice location:
  • Phone: 847-459-8700
  • Fax:
Mailing address:
  • Phone: 224-612-3150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.025475
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: