Provider Demographics
NPI:1366837676
Name:FORNEY, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:FORNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 W ILLINOIS ST
Mailing Address - Street 2:APT G
Mailing Address - City:BRIMFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:61517-9646
Mailing Address - Country:US
Mailing Address - Phone:815-600-0845
Mailing Address - Fax:
Practice Address - Street 1:2200 FORT JESSE RD
Practice Address - Street 2:SUITE 240
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6286
Practice Address - Country:US
Practice Address - Phone:815-600-0845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2017-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070021413225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist