Provider Demographics
NPI:1538327002
Name:MATTALIANO, JOANN MARIE (PTA)
Entity Type:Individual
Prefix:MS
First Name:JOANN
Middle Name:MARIE
Last Name:MATTALIANO
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 1:9629 S MILLARD AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2910
Mailing Address - Country:US
Mailing Address - Phone:708-426-5645
Mailing Address - Fax:708-425-0349
Practice Address - Street 1:9629 S MILLARD AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2910
Practice Address - Country:US
Practice Address - Phone:708-426-5645
Practice Address - Fax:708-425-0349
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160001349225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant