MEDICARE: MS. SANDRA MARIA DE JESUS PT,DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251P0200X	Pediatric Physical Therapist	070015855	IL

General Provider Information

NPI Number	:	1326352899
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SANDRA MARIA DE JESUS PT,DPT

Provider Business Mailing Address
First Line	:	3630 N. HARLEM AVENUE
Second Line	:	214
City	:	CHICAGO
State	:	IL
Zip	:	60634-3194
Country	:	US
Telephone Number	:	773-848-4846
Fax Number	:

Provider Business Practice Location Address
First Line	:	3630 N. HARLEM AVENUE
Second Line	:	214
City	:	CHICAGO
State	:	IL
Zip	:	60634-3194
Country	:	US
Telephone Number	:	773-848-4846
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2010
Last Update Date	:	07/27/2010

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