Provider Demographics
NPI:1558140426
Name:PONO, ANDREW LAWRENCE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:LAWRENCE
Last Name:PONO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 S FALCON DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-4212
Mailing Address - Country:US
Mailing Address - Phone:224-294-4250
Mailing Address - Fax:
Practice Address - Street 1:1860 W WINCHESTER RD STE 108
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5312
Practice Address - Country:US
Practice Address - Phone:847-573-9486
Practice Address - Fax:847-549-6139
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.0278052251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics