Provider Demographics
NPI:1437376936
Name:BROWN, LIESEL A (PT)
Entity Type:Individual
Prefix:
First Name:LIESEL
Middle Name:A
Last Name:BROWN
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 1:1222 WASHINGTON CT
Mailing Address - Street 2:STE 200
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2615
Mailing Address - Country:US
Mailing Address - Phone:773-919-0828
Mailing Address - Fax:
Practice Address - Street 1:1222 WASHINGTON CT
Practice Address - Street 2:STE 200
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2615
Practice Address - Country:US
Practice Address - Phone:773-919-0828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070009534225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL567700OtherMEDICARE GROUP NUMBER
IL568080OtherMEDICARE GROUP NUMBER
IL1619908OtherBCBS IL GROUP
IL568150OtherMEDICARE GROUP NUMBER
IL567700OtherMEDICARE GROUP NUMBER
ILK48243Medicare PIN
ILL76793Medicare PIN