=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740980820
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTOPHER WASHINGTON PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2023
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1525 E 53RD ST STE 627
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60615-4575
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-324-0953
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8916 S BENNETT AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-2917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-576-3693
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 160.008328
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------