=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740605997
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY WADAS PT, DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2014
-----------------------------------------------------
Last Update Date | 10/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18210 LA GRANGE RD STE 100
-----------------------------------------------------
City | TINLEY PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60487-7723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-429-8700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7425 FALLING LEAF CIR
-----------------------------------------------------
City | SCHERERVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46375-5324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-924-4239
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 070020449
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------