Provider Demographics
NPI:1558753913
Name:WOOTEN, ANNIE (PT)
Entity Type:Individual
Prefix:MISS
First Name:ANNIE
Middle Name:
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 W STEIDL RD
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:IL
Mailing Address - Zip Code:61944-5995
Mailing Address - Country:US
Mailing Address - Phone:217-251-3184
Mailing Address - Fax:
Practice Address - Street 1:1011 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:IL
Practice Address - Zip Code:61944-1145
Practice Address - Country:US
Practice Address - Phone:217-465-5376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070021238225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist