MEDICARE: MS. JOANN MARIE MATTALIANO PTA

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	225200000X	Physical Therapy Assistant	160001349	IL

General Provider Information

NPI Number	:	1538327002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JOANN MARIE MATTALIANO PTA

Provider Business Mailing Address
First Line	:	9629 S MILLARD AVE
Second Line	:
City	:	EVERGREEN PARK
State	:	IL
Zip	:	60805-2910
Country	:	US
Telephone Number	:	708-426-5645
Fax Number	:	708-425-0349

Provider Business Practice Location Address
First Line	:	9629 S MILLARD AVE
Second Line	:
City	:	EVERGREEN PARK
State	:	IL
Zip	:	60805-2910
Country	:	US
Telephone Number	:	708-426-5645
Fax Number	:	708-425-0349

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

Provider Enumeration Date	:	05/30/2008
Last Update Date	:	05/30/2008

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