Provider Demographics
NPI:1508989583
Name:RANDALL, MARY JANE (PTA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JANE
Last Name:RANDALL
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 1:268 STRATHMORE LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1932
Mailing Address - Country:US
Mailing Address - Phone:630-893-7479
Mailing Address - Fax:
Practice Address - Street 1:268 STRATHMORE LN
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1932
Practice Address - Country:US
Practice Address - Phone:630-893-7479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant