Provider Demographics
NPI:1376107516
Name:IBARRA-BRENNEMAN, GHISLAINE IMARIS (DPT)
Entity Type:Individual
Prefix:
First Name:GHISLAINE
Middle Name:IMARIS
Last Name:IBARRA-BRENNEMAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:GHISLAINE
Other - Middle Name:IMARIS
Other - Last Name:IBARRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:3011 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657
Practice Address - Country:US
Practice Address - Phone:773-661-0240
Practice Address - Fax:773-289-1541
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.024199225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist