Provider Demographics
NPI:1003090309
Name:DAVIS, CHAD (PTA)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 CENTURION LN
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-2580
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:806 LARAWAY RD
Practice Address - Street 2:#808
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-2694
Practice Address - Country:US
Practice Address - Phone:815-462-8416
Practice Address - Fax:815-462-8425
Is Sole Proprietor?:No
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant