Provider Demographics
NPI:1033412002
Name:POTISUK, STEPHEN S (PT)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:S
Last Name:POTISUK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44W121 EMPIRE RD
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-8256
Mailing Address - Country:US
Mailing Address - Phone:630-337-9545
Mailing Address - Fax:
Practice Address - Street 1:44W121 EMPIRE RD
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-8256
Practice Address - Country:US
Practice Address - Phone:630-337-9545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.011469225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist