Provider Demographics
NPI:1336684364
Name:GRUS, ANN MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:ANN MARIE
Middle Name:
Last Name:GRUS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:581 WILLIAM R LATHAM SR DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-2317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:581 WILLIAM R LATHAM SR DR
Practice Address - Street 2:SUITE 301
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2317
Practice Address - Country:US
Practice Address - Phone:815-932-9338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.007401225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant