Provider Demographics
NPI:1851787311
Name:WADE, VANESSA (DPT)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:WADE
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 1:1743 N CLEVELAND AVE
Mailing Address - Street 2:1F
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5699
Mailing Address - Country:US
Mailing Address - Phone:614-832-0374
Mailing Address - Fax:
Practice Address - Street 1:345 E SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2654
Practice Address - Country:US
Practice Address - Phone:614-832-0374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-11
Last Update Date:2015-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.020611225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist