Provider Demographics
NPI:1760993901
Name:VONGONTARD, ELIZABETH (DPT)
Entity Type:Individual
Prefix:MISS
First Name:ELIZABETH
Middle Name:
Last Name:VONGONTARD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 N LINCOLN PARK W UNIT 1110
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-4708
Mailing Address - Country:US
Mailing Address - Phone:314-766-3930
Mailing Address - Fax:
Practice Address - Street 1:2515 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2730
Practice Address - Country:US
Practice Address - Phone:312-227-6240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070023287225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist