Provider Demographics
NPI:1003351230
Name:SIMMONS, MARGUERITE
Entity Type:Individual
Prefix:
First Name:MARGUERITE
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARGUERITE
Other - Middle Name:
Other - Last Name:EARLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:121 DES PLAINES AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-3316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 DES PLAINES AVE
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-3316
Practice Address - Country:US
Practice Address - Phone:708-355-1031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-26
Last Update Date:2016-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.001468225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant