Provider Demographics
NPI:1023203056
Name:TALLCOTT, DEBRA SUE (PT)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:SUE
Last Name:TALLCOTT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1426 N 2250TH AVE
Mailing Address - Street 2:
Mailing Address - City:MENDON
Mailing Address - State:IL
Mailing Address - Zip Code:62351-2907
Mailing Address - Country:US
Mailing Address - Phone:217-936-2534
Mailing Address - Fax:
Practice Address - Street 1:1426 N 2250TH AVE
Practice Address - Street 2:
Practice Address - City:MENDON
Practice Address - State:IL
Practice Address - Zip Code:62351-2907
Practice Address - Country:US
Practice Address - Phone:217-936-2534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01183225100000X
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist