Provider Demographics
NPI:1578821781
Name:WANTUCK, PAULINE M
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:M
Last Name:WANTUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4553 HARVEY AVE
Mailing Address - Street 2:
Mailing Address - City:WESTERN SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60558-1648
Mailing Address - Country:US
Mailing Address - Phone:773-844-3517
Mailing Address - Fax:708-246-6232
Practice Address - Street 1:4553 HARVEY AVE
Practice Address - Street 2:
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558-1648
Practice Address - Country:US
Practice Address - Phone:773-844-3517
Practice Address - Fax:708-246-6232
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160001489225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant