Provider Demographics
NPI:1760720676
Name:PONTILLO, ROSEANNE (MSOM, LAC,BS)
Entity Type:Individual
Prefix:MS
First Name:ROSEANNE
Middle Name:
Last Name:PONTILLO
Suffix:
Gender:F
Credentials:MSOM, LAC,BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3306 ROYAL WOODS DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-4793
Mailing Address - Country:US
Mailing Address - Phone:847-602-2114
Mailing Address - Fax:
Practice Address - Street 1:3306 ROYAL WOODS DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-4793
Practice Address - Country:US
Practice Address - Phone:847-602-2114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.011005171100000X
WI728-055171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist