Provider Demographics
NPI:1275601817
Name:SO, AMY BETH (PT)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:BETH
Last Name:SO
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 1:2868 TANAGA BASIN
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-2982
Mailing Address - Country:US
Mailing Address - Phone:815-485-0619
Mailing Address - Fax:
Practice Address - Street 1:19821 S. LAGRANGE ROAD
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448
Practice Address - Country:US
Practice Address - Phone:708-478-6996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
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
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK17229Medicare ID - Type Unspecified