Provider Demographics
NPI:1497076103
Name:AUSSIEKER, RUSSA (PTA)
Entity Type:Individual
Prefix:
First Name:RUSSA
Middle Name:
Last Name:AUSSIEKER
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 1:550 FRONTAGE RD
Mailing Address - Street 2:SUITE 2415
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-1202
Mailing Address - Country:US
Mailing Address - Phone:847-441-5593
Mailing Address - Fax:847-441-0734
Practice Address - Street 1:201 LOCUST ST
Practice Address - Street 2:
Practice Address - City:MINONK
Practice Address - State:IL
Practice Address - Zip Code:61760-1511
Practice Address - Country:US
Practice Address - Phone:309-432-2557
Practice Address - Fax:309-432-3330
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160003378225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant