Provider Demographics
NPI:1245582428
Name:DIAZ, LEON (PTA)
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 DANVERS
Mailing Address - Street 2:
Mailing Address - City:SCHAMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60194
Mailing Address - Country:US
Mailing Address - Phone:847-895-1838
Mailing Address - Fax:
Practice Address - Street 1:4538 N. BEACON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640
Practice Address - Country:US
Practice Address - Phone:773-275-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160006126225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant