Provider Demographics
NPI:1689922833
Name:MASEMORE, POLLY SUE (PT)
Entity Type:Individual
Prefix:MRS
First Name:POLLY
Middle Name:SUE
Last Name:MASEMORE
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 1:2200 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4364
Mailing Address - Country:US
Mailing Address - Phone:309-662-3311
Mailing Address - Fax:309-662-1628
Practice Address - Street 1:2200 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4364
Practice Address - Country:US
Practice Address - Phone:309-662-3311
Practice Address - Fax:309-662-1628
Is Sole Proprietor?:No
Enumeration Date:2012-08-20
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.004726225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist