=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144821380
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY GRASSANO DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2020
-----------------------------------------------------
Last Update Date | 07/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1644 E 53RD ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60615-4489
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-241-6450
-----------------------------------------------------
Fax | 773-241-6501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2122 YORK RD STE 300
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-1925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-575-1980
-----------------------------------------------------
Fax | 630-928-5080
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | LPT-33149
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 070025662
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------