Provider Demographics
NPI:1396196309
Name:WANTA, LEONARD (PT)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:
Last Name:WANTA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 CIRCLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-8379
Mailing Address - Country:US
Mailing Address - Phone:630-789-8962
Mailing Address - Fax:630-654-3088
Practice Address - Street 1:126 CIRCLE RIDGE DR
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-8379
Practice Address - Country:US
Practice Address - Phone:630-789-8962
Practice Address - Fax:630-654-3088
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070003801225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist