Provider Demographics
NPI:1073191136
Name:GLADIS, AMY MARIE (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:GLADIS
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 ANDERSON DR
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-9694
Mailing Address - Country:US
Mailing Address - Phone:630-485-1304
Mailing Address - Fax:
Practice Address - Street 1:610 S MAPLE AVE STE 3500
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-2801
Practice Address - Country:US
Practice Address - Phone:708-934-7062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960051442255A2300X
IL070025778225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty