Provider Demographics
NPI:1578639704
Name:PETERS, THOMAS A II (PTA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:PETERS
Suffix:II
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 1:4318 N SPAULDING AVE # 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-1237
Mailing Address - Country:US
Mailing Address - Phone:773-899-0831
Mailing Address - Fax:
Practice Address - Street 1:420 THATCHER AVE
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1635
Practice Address - Country:US
Practice Address - Phone:708-427-3650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
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