Provider Demographics
NPI:1619463700
Name:DEINLA, MARY GRACE CORPIN (PT)
Entity Type:Individual
Prefix:
First Name:MARY GRACE
Middle Name:CORPIN
Last Name:DEINLA
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 1:706 LANDWEHR RD
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2310
Mailing Address - Country:US
Mailing Address - Phone:224-567-1649
Mailing Address - Fax:847-305-5886
Practice Address - Street 1:706 LANDWEHR RD
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2310
Practice Address - Country:US
Practice Address - Phone:224-567-1649
Practice Address - Fax:847-305-5886
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014879225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist