Provider Demographics
NPI:1114055852
Name:WHEATON, MARY LOUISE (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:WHEATON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2289 LONG LN
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-7450
Mailing Address - Country:US
Mailing Address - Phone:815-519-5316
Mailing Address - Fax:815-544-6871
Practice Address - Street 1:2289 LONG LN
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-7450
Practice Address - Country:US
Practice Address - Phone:815-519-5316
Practice Address - Fax:815-544-6871
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist