=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750608089
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAXIME R SENECAL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2010
-----------------------------------------------------
Last Update Date | 04/26/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 222 S RIVERSIDE PLZ
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60606-5808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-416-3804
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 918 S HUMPHREY AVE
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60304-1721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 160000877
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------