Provider Demographics
NPI:1407804719
Name:ILLIUS, MARIE LOUISE (PTA)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:LOUISE
Last Name:ILLIUS
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 1:33865 BROKAW RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA STATION
Mailing Address - State:OH
Mailing Address - Zip Code:44028-9779
Mailing Address - Country:US
Mailing Address - Phone:440-748-3674
Mailing Address - Fax:
Practice Address - Street 1:5700 LOMBARDO CTR
Practice Address - Street 2:ROCK RUN NORTH SUITE 205
Practice Address - City:SEVEN HILLS
Practice Address - State:OH
Practice Address - Zip Code:44131-2540
Practice Address - Country:US
Practice Address - Phone:216-447-1149
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA.04976171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor