Provider Demographics
NPI:1629047568
Name:HALSTEAD, THANE ROCKWELL III (ATC)
Entity Type:Individual
Prefix:MR
First Name:THANE
Middle Name:ROCKWELL
Last Name:HALSTEAD
Suffix:III
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2503 N WASHTENAW AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-1815
Mailing Address - Country:US
Mailing Address - Phone:773-213-2224
Mailing Address - Fax:
Practice Address - Street 1:1201 W NEW YORK ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-3667
Practice Address - Country:US
Practice Address - Phone:630-301-6629
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096-00003882255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer