Provider Demographics
NPI:1598093841
Name:GOLEM, BERTHA XITLALY (DPT)
Entity Type:Individual
Prefix:MISS
First Name:BERTHA
Middle Name:XITLALY
Last Name:GOLEM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:BERTHA
Other - Middle Name:XITLALY
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:600 N MCCLURG CT
Mailing Address - Street 2:STE A312
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3011
Mailing Address - Country:US
Mailing Address - Phone:312-337-8840
Mailing Address - Fax:312-337-9334
Practice Address - Street 1:600 N MCCLURG CT
Practice Address - Street 2:STE A312
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3011
Practice Address - Country:US
Practice Address - Phone:312-337-8840
Practice Address - Fax:312-337-9334
Is Sole Proprietor?:No
Enumeration Date:2009-11-25
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014584225100000X
IL070.014584225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist