Provider Demographics
NPI:1396817037
Name:WIGUTOW, MARLA (PT)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:
Last Name:WIGUTOW
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 1:2835 N SHEFFIELD AVE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5081
Mailing Address - Country:US
Mailing Address - Phone:773-883-2190
Mailing Address - Fax:773-935-9374
Practice Address - Street 1:954 W GRACE ST
Practice Address - Street 2:F201
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3959
Practice Address - Country:US
Practice Address - Phone:773-528-6054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
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