Provider Demographics
NPI:1679007900
Name:BELCASTER, MADONNA MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:MADONNA
Middle Name:MARIE
Last Name:BELCASTER
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 1:6500 W 65TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-4962
Mailing Address - Country:US
Mailing Address - Phone:708-496-1515
Mailing Address - Fax:708-496-3422
Practice Address - Street 1:6500 W 65TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-4962
Practice Address - Country:US
Practice Address - Phone:708-496-1515
Practice Address - Fax:708-496-3422
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160003167225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant