Provider Demographics
NPI:1083013395
Name:FREY, SERAH AMANDA (DPT)
Entity Type:Individual
Prefix:
First Name:SERAH
Middle Name:AMANDA
Last Name:FREY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E WALTON ST
Mailing Address - Street 2:STE. 700
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-1448
Mailing Address - Country:US
Mailing Address - Phone:312-642-3963
Mailing Address - Fax:312-642-3966
Practice Address - Street 1:850 BUSSE HWY
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-2302
Practice Address - Country:US
Practice Address - Phone:847-384-8511
Practice Address - Fax:847-384-8513
Is Sole Proprietor?:No
Enumeration Date:2014-08-22
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.020787225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400173921Medicare PIN