=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104581289
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEND PHYSICAL THERAPY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2021
-----------------------------------------------------
Last Update Date | 11/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2525 N ELSTON AVE STE C200
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-2042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-978-4527
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4345 N PAULINA ST # 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60613-1219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-978-4527
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | JESSICA STROUP
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 815-978-4527
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------