Provider Demographics
NPI:1821395773
Name:LAIS, TONI MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:TONI
Middle Name:MARIE
Last Name:LAIS
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 1:120 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:IL
Mailing Address - Zip Code:61530-1182
Mailing Address - Country:US
Mailing Address - Phone:309-467-3220
Mailing Address - Fax:309-467-3240
Practice Address - Street 1:120 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:IL
Practice Address - Zip Code:61530-1182
Practice Address - Country:US
Practice Address - Phone:309-467-3220
Practice Address - Fax:309-467-3240
Is Sole Proprietor?:No
Enumeration Date:2011-02-11
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.017501225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ19402Medicare UPIN