Provider Demographics
NPI:1760794325
Name:CLAM, DAWN MAUREEN TAN (PT)
Entity Type:Individual
Prefix:
First Name:DAWN MAUREEN
Middle Name:TAN
Last Name:CLAM
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 1:12262 WINNE LN
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-0045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2406 HARTLAND RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-9763
Practice Address - Country:US
Practice Address - Phone:912-380-0159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-11
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8218225100000X
GAPT009885225100000X
IL070019095225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070019095OtherILLINOIS STATE BOARD OF PHYSICAL THERAPY
GAPT009885OtherSTATE BOARD OF PHYSICAL THERAPY
CT8218OtherCONNECTICUT STATE BOARD OF PHYSICAL THERAPY