Provider Demographics
NPI:1083738561
Name:GUMABONG, JANETTE C (PT)
Entity Type:Individual
Prefix:
First Name:JANETTE
Middle Name:C
Last Name:GUMABONG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JANETTE
Other - Middle Name:A
Other - Last Name:CASTILLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-6250
Mailing Address - Fax:
Practice Address - Street 1:16139 WEBER RD
Practice Address - Street 2:
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-8742
Practice Address - Country:US
Practice Address - Phone:815-836-3403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015404225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00931568OtherMEDICARE RAILROAD
ILK36984Medicare PIN
ILP00615841Medicare PIN
ILP00931568OtherMEDICARE RAILROAD
ILP00461119Medicare PIN