Provider Demographics
NPI:1053066290
Name:IRVIN, SYDNEY ELIZABETH (PTA)
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:ELIZABETH
Last Name:IRVIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 HILL ST
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3241
Mailing Address - Country:US
Mailing Address - Phone:402-672-5011
Mailing Address - Fax:
Practice Address - Street 1:2600 N ANNIE GLIDDEN RD
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-1207
Practice Address - Country:US
Practice Address - Phone:815-758-2477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008151225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant