Provider Demographics
NPI:1518122241
Name:JOHN, WILSON (PTA)
Entity Type:Individual
Prefix:MR
First Name:WILSON
Middle Name:
Last Name:JOHN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6729 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2307
Mailing Address - Country:US
Mailing Address - Phone:847-501-0035
Mailing Address - Fax:
Practice Address - Street 1:5145 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3661
Practice Address - Country:US
Practice Address - Phone:773-878-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.001586225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant