Provider Demographics
NPI:1619220316
Name:SUTTON, MARIE (PTA)
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:
Last Name:SUTTON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7510 WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60081-8918
Mailing Address - Country:US
Mailing Address - Phone:815-675-6510
Mailing Address - Fax:
Practice Address - Street 1:2507 N RICHMOND RD
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60051-5407
Practice Address - Country:US
Practice Address - Phone:815-363-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.001802225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant