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General NPI Number Information
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NPI Number | 1215696893
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Entity Type | Individual
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Provider Name | BRIANNA DANTA PTA
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Gender | Female
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Dates
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Enumeration Date | 12/10/2021
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Last Update Date | 12/10/2021
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Provider Practice Location Address
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Address Line | 183 N MAIN ST
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City | MANTENO
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State | IL
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Zip | 60950-1243
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Country | US
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Telephone | 815-261-0044
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Fax |
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Provider Business Mailing Address
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Address Line | 17130 PRIME BLVD
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City | LOCKPORT
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State | IL
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Zip | 60441-1311
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Country | US
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Telephone | 708-518-3508
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 160.008751
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License Number State | IL
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