Provider Demographics
NPI:1679619407
Name:WIRTH-PATTULLO, VIRGINIA MARIA (PT)
Entity Type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:MARIA
Last Name:WIRTH-PATTULLO
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 1:129 ELMORE ST
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-3519
Mailing Address - Country:US
Mailing Address - Phone:847-823-5925
Mailing Address - Fax:
Practice Address - Street 1:1030 N CLARK ST
Practice Address - Street 2:SUITE 500
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-5467
Practice Address - Country:US
Practice Address - Phone:312-238-7767
Practice Address - Fax:312-238-7709
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist