Provider Demographics
NPI:1851516173
Name:VITHOULKAS, ANASTASIA MARIA (DT)
Entity Type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:MARIA
Last Name:VITHOULKAS
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18236 CLEAR CREEK XING
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-5237
Mailing Address - Country:US
Mailing Address - Phone:708-478-5596
Mailing Address - Fax:708-478-6773
Practice Address - Street 1:18236 CLEAR CREEK XING
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5237
Practice Address - Country:US
Practice Address - Phone:708-478-5596
Practice Address - Fax:708-478-6773
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILAV42821006P222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist